CARE HOME ADULTS 18-65
Chy Colom Agar Road Truro Cornwall TR1 1JU Lead Inspector
Diana Penrose Unannounced 25 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Chy Colom Address Agar Road Truro Cornwall TR1 1JU 01872 262414 01872 262355 chycolom@addaction.org.uk Addaction Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Roland George Bence Care Home 12 Category(ies) of Past or present alcohol dependence (12) registration, with number Past or present drug dependence (12) of places Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 08/02/05 Brief Description of the Service: Chy Colom is a detached property positioned in a residential area of Truro, close to the City Centre. There is a large garden at the front of the building and limited car parking space. Chy Colom was built over a hundred years ago as a vicarage. It still has many of the original ecclesiastical fittings throughout the home, which add character. A substantial refurbishment was completed in January 2004; this significantly improved the accommodation. The home has three floors; on the ground floor there is a large lounge, a dining room and a counselling room. Another communal room has been converted into a study room with computers. The home is non-smoking but there is a facility at the back of the home for those who wish to smoke. The bedrooms are on the first and second floors; four of them are shared rooms. Access to these floors is by stairs only, wheelchair users or service users unable to climb stairs cannot be accommodated at the home. The home operates a twelve-week rehabilitation programme. Service users are only accepted onto the programme following a very comprehensive assessment. Appropriately qualified and experienced staff work in the home. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector visited Chy Colom on the 25 August 2005 and spent four and a half hours at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance to the requirements that were identified in the last inspection report dated 08.02.05. In addition the inspector focused on the following key areas of care: choice of home, assessment, health care, leisure, complaints, some of the environment and some management areas. On the day of inspection 3 residents were living in the home. The methods used to undertake the inspection were to meet with the Registered Manager and Residential Services Manager to gain their views on the services that Chy Colom offer. The residents declined the offer to talk to the Inspector but said they were happy at the home and satisfied with the programme. Chy Colom’s records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. What the service does well:
The home provides a twelve week structured substance abuse secondary rehabilitation programme. A thorough assessment and an interview are undertaken prior to any client being accepted onto the programme. An individual care plan is compiled from the assessment. Each resident is allocated a key worker to work closely with them throughout their stay at the home. There are strict house rules and the residents are informed of these at the outset. Following the first two weeks of the programme residents can become more independent and go out into the community. Representatives from Alcoholics Anonymous and Narcotics Anonymous, for example, visit the home to talk to the residents and a great deal of creative work takes place with the staff. Residents can continue their education and there are computers in the home for residents to use; one has internet access. Residents are assisted with their benefits and helped to find suitable employment and housing if necessary on leaving the home. A healthy diet is encouraged and there was a good stock of fresh fruit and vegetables in the home on the day of the inspection. The residents help with the cooking and cleaning in the home. There is a list of household tasks and they are responsible for their delegation and making sure they get done. Medicines are dealt with safely and a system of supervised self-administration is employed with records kept. The home has suitable policies and guidelines to inform the staff. There are systems in place to safeguard the residents from abuse and all staff are booked onto training courses.
Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 6 The home is set in tidy grounds and is well maintained. It was warm and clean on the day of inspection and there were no unpleasant odours. There are adequate laundry facilities and staff are trained in infection control. There is a two-month induction programme for new staff and they are issued with a staff handbook. All staff are required to undertake NVQ level 3 in care and core competency training. Staff appraisals take place annually and training needs are identified. The Registered Manager has worked at the home for some years and is competent to run the home. Residents meetings are held daily giving an opportunity for residents to air their views and get involved in the running of the home. In order to improve the facilities or the programme residents are interviewed prior to leaving and sent a survey form to complete six months later. The safety of the residents and staff is paramount and the management endeavour to ensure that working practices are safe. Staff receive relevant statutory training, for example moving and handling, fire and health and safety. What has improved since the last inspection? What they could do better:
A copy of the statement of purpose and residents guide must be sent to the Commission for Social Care Inspection when it is printed. Any quality assurance survey results must also be sent to the commission along with the annual development plan for the home. The adult protection policy must include the reporting of incidents and allegations of abuse to the Commission. There must be a business and financial plan for the home and it must be available for inspection by the CSCI inspectors at any time. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2 Prospective residents are given information about the home enabling them to make an informed decision. Residents are only admitted to the home following an in depth assessment of their needs to ensure the home can provide appropriate care. EVIDENCE: The home has a statement of purpose, service users guide and a colour brochure. The documents have been updated but printing is awaited due to the imminent change in Responsible individual. Copies of the new documents must be sent to the Commission. There are various forms to be completed prior to any admission to the home. A contact sheet is completed with the initial enquiry and a flier is sent to the individual requesting an informal visit. The client then completes an application form. The referring agent completes a rehabilitation referral form as well prior to the client being interviewed by a relevant member of staff at the home. Other professionals only get involved if there are special needs to take into account. The documents inspected had been completed very thoroughly. A care plan is compiled from the initial paperwork. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not inspected on this occasion. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,16 & 17 Residents take part in appropriate activities and are assisted with training and education to encourage their independence and individuality. There is a strict programme with house rules but residents’ rights and individual choice are respected. Dietary needs of residents are well catered for with a varied selection of food available to meet their taste and preference. EVIDENCE: Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 12 Each resident has a key worker to work very closely with them. Residents can attend community groups, Link to Learning and college courses after the first two weeks of the programme. Alcoholics Anonymous and Narcotics Anonymous representatives visit the home. Creative work is undertaken as part of the therapy. Staff do some teaching and there are computers with internet access. Residents are helped to find employment before leaving the home as necessary. Residents are assisted with their benefits. The home operates a very structured programme that aims for empowerment, responsibility and choice. After the first two weeks of the programme residents can be more independent and can go out providing the staff know where they are going. There are ‘house rules’ that residents are made aware of from the outset. Residents have their own possessions with them and all residents are issued with a key to their room. The daily household duties are organised and undertaken by the service users. The home has a no smoking policy but there is a facility at the back of the home for smoking. A healthy diet is encouraged in the home and there was a good stock of fresh fruit and vegetables on the day of the inspection. The residents have grown courgettes. The menu is negotiated with the residents and choices are available, they are involved in the preparation of meals. A special meal is served when a resident leaves the home and chosen by the resident. The cook has achieved the intermediate food hygiene certificate and has produced a health and hygiene handout for residents. She has cleaning schedules and the residents are actively involved with the cleaning. The kitchen is very clean and the Environmental Health Officer has given the home a very good report. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 There are suitable systems and policies in place for dealing with residents medicines and assure residents safety. EVIDENCE: Residents bring their medicines with them into the home. There is a system of supervised self-administration of medications in the home. Medicine administration records include a sheet for both staff and residents to sign. No controlled drugs are held in the home. The home has a copy of The Royal Pharmaceutical Guidelines for the Administration of medicines in Care Homes and a medicines policy. There are medicine reference books for staff to refer to. Medication training for staff is undertaken as part of the core competency training. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Arrangements are in place to protect residents from possible risk of harm or abuse; an addition to the policy will ensure these are robust. EVIDENCE: There is an Adult Protection and whistle blowing policy in the home. There are also copies of the new multi-agency policy for Cornwall. The Adult Protection policy must state that incidents of abuse / alleged abuse must be reported to the Commission for Social Care Inspection, with contact details. The Registered Manager has attended ‘alerter’ training organised by Social Services and most of the staff are now booked onto the same course. The course pack is available to staff. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home was clean and free from offensive odours making it a pleasant hygienic place to live in. EVIDENCE: The home provides a comfortable, homely environment and was clean and tidy on the day of inspection, with no offensive odours. The grounds were tidy and attractive and easily accessible. The residents participate in the gardening. The home is not accessible to wheel chair users. There is adequate heating, lighting and ventilation. The home is well maintained and there is a programme for redecoration in progress. Staff have attended infection control training and the course information pack is available in the office. The laundry facilities are adequate for the size of the home and are situated off the garage at the back of the home. There are good hand-washing facilities for staff and protective clothing is provided. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 Recruitment procedures undertaken by the Registered Manager are robust and offer protection to the service users. Staff receive training relevant to their roles to ensure that residents needs are met appropriately. EVIDENCE: Copies of the recruitment records held at CADA House have been sent to the home. The Registered Manager is in the process of sorting these into the appropriate files. Consequently not all files inspected held all of the relevant information. The home operates an equal opportunities policy There is a two-month induction programme for new staff that includes a checklist to be signed off and a staff hand book. There is a training needs analysis undertaken annually for all staff and most training takes place in house. Appraisals each year identify training needs. Core competency training is undertaken, but the NVQ training for all staff takes priority. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 & 42 The manager is competent and experienced and residents benefit from a well run home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place, reporting to the Commission will ensure regulatory requirements. The management promote the health, safety and welfare of service users, staff and visitors however, further measures are required to minimise risks. EVIDENCE: The Registered Manager is competent and has the relevant knowledge and experience to run the home. He is currently undertaking the Registered Managers’ Award as well as other relevant training. He has recently attended an adult protection course run by Social Services. There are an abundance of policies and procedures in place for staff. Daily meetings are held when residents can air their views; there are also group feedback forms for residents to complete. Each resident is invited to attend an exit interview to ascertain their feelings and experience of Chy Colom. The home also does a survey of resident’s views six months after they leave the home and these have been helpful and positive. The survey and exit interview
Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 18 results must be collated and a copy of the report and action plan sent to the CSCI. A regional manager undertakes a quarterly visit and writes a report for the Registered Manager, which is useful. Management endeavour to ensure that working practices are safe. Statutory training for staff takes place. The accident book complies with data protection legslation. There were few accidents in the home. COSHH data sheets are in place and relevant copies were seen in the kitchen. Hazardous substances are stored safely and securely. The health and safety risk assessments must be completed. Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x x 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Chy Colom Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 x D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement A copy of the statement of purpose and service users guide must be sent to the Commission for Social Care Inspection The Adult Protection policy must state that incidents of abuse / alleged abuse must be reported to the Commission for Social Care Inspection, with contact details(previous timescale of 02/05/05 not met) The survey and exit interview results must be collated and a copy of the report and action plan sent to the CSCI The annual development plan for the home must be sent to the Commission (previous timescale of 21/03/05 not met) The health and safety risk assessments must be completed. There must be a business and financial plan for the home that is available for inspection(previous timescale of 21/03/05 not met) Timescale for action 24/10/05 2. 23 13 24/10/05 3. 39 24 30/01/06 4. 39 24 30/11/05 5. 6. 42 43 13 25 30/11/05 30/11/05 Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Chy Colom D52-D04 S63547 Chy Colom V243223 250805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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