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Inspection on 11/07/06 for Colbury House Nursing & Residential Home

Also see our care home review for Colbury House Nursing & Residential Home for more information

This inspection was carried out on 11th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A comprehensive pre assessment process assures residents that their needs can be met by the home when they move into the home. Individualised care plans that are reviewed regularly ensure that the personal, health and social needs of those living at the home are met. Robust medications procedures promote the health of the residents. A variety of activities are available for residents to participate in if they wish. Residents are encouraged to be as independent as possible, including accessing the community independently if they are able to. Complaints are dealt with effectively and are seen as an integral way to improve the service offered. Residents are protected by a work force that is aware of adult protection issues as well as robust recruitment procedures. Creative rotas and effective staff training ensure that resident`s needs can be met at the home. Residents live in a clean, safe environment with large gardens, cheerful communal rooms, personalised bathrooms and specialist equipment. Resident`s benefit from a management structure that supports an open and transparent culture.

What has improved since the last inspection?

Fire safety records confirm that all staff members have received the recommended fire safety training.

What the care home could do better:

The registered provider does not produce monthly reports about the running of the home including the views of residents; these reports will contribute to the quality auditing of the home. Quality auditing of the service would also be enhanced by the regular use of the auditing tool that the home has chosen to use. Documenting of activities attended by residents is not kept up to date; an up to date record of this would allow the service to effectively evaluate the response to activities organised.

CARE HOMES FOR OLDER PEOPLE Colbury House Nursing & Residential Home Hill Street Totton Southampton Hampshire SO40 2RX Lead Inspector Gina Pickering Unannounced Inspection 12:00 11th July 2006 & 14th July 2006 X10015.doc Version 1.40 Page 1 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 Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 2 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery 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. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colbury House Nursing & Residential Home Address Hill Street Totton Southampton Hampshire SO40 2RX 023 8086 9876 023 8086 7119 margaret@colbury.com Telephone number Fax number Email address Provider Web 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 Jeffrey Collins Mrs Margaret Josephine Collins Christine Joy Harris Care Home 40 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (40), of places Physical disability (6), Physical disability over 65 years of age (28) Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 6 beds may be used at any time for service users in the category of PD between the ages of 50-65 Date of last inspection 21st October 2005 Brief Description of the Service: Colbury House Nursing and Residential Home is situated in Totton, in a quiet lane, surrounded by pleasant countryside and close to the New Forest. There are close links to the M27 motorway and the nearby amenities of Totton and Southampton. The home provides accommodation for up to forty people over the age of sixty five. Up to seventeen of these places are available for people with dementia and twenty eight for residents with a physical disability. Up to six places can be used for residents with a physical disability aged between fifty and sixty five years of age. Accommodation is arranged on two levels. The home has a pleasant lounge with views over the home’s gardens and there is a separate dining room. There are seven shared and twenty six single rooms. The home benefits from twenty eight bedrooms with en-suite facilities. Nine of the residents are accommodated in the Coach House, a separate building with its’ own lounge and dining area and bathroom. Residents that live in the Coach House ca use the lounge and dining area in the main building if they wish to. Building work has recently commenced to create additional bedrooms and communal facilities. The home is owned by Mr and Mrs Collins. Mrs Collins takes an active part in the day to day running of the service. Christine Harris is the registered manager of the home. Fees at the home range from £327 per week for persons needing person care up to £700 per week for those needing nursing care. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process took into account information contained within the pre inspection document completed by the home, issues raised in a complaint received by the commission and two site visits on 11th and 14th July. During the site visits the inspector spoke with the registered providers, the deputy matron, trained nurses, care staff, the cook and cleaning staff, ten residents and two visitors as well as looking at documentation. Information received in the form of one anonymous complaint to the commission has been considered throughout the inspection process. The registered manager was on leave at the time of the site visits. The service users at the home prefer to be known as residents and this is respected in the writing of this report. What the service does well: A comprehensive pre assessment process assures residents that their needs can be met by the home when they move into the home. Individualised care plans that are reviewed regularly ensure that the personal, health and social needs of those living at the home are met. Robust medications procedures promote the health of the residents. A variety of activities are available for residents to participate in if they wish. Residents are encouraged to be as independent as possible, including accessing the community independently if they are able to. Complaints are dealt with effectively and are seen as an integral way to improve the service offered. Residents are protected by a work force that is aware of adult protection issues as well as robust recruitment procedures. Creative rotas and effective staff training ensure that resident’s needs can be met at the home. Residents live in a clean, safe environment with large gardens, cheerful communal rooms, personalised bathrooms and specialist equipment. Resident’s benefit from a management structure that supports an open and transparent culture. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. The good practice of assessment ensures that when a person moves into the home their needs can be met. The home does not offer intermediate care. EVIDENCE: Resident’s documents contain assessments that are performed prior to their admission to the home. The assessment covers aspects of the person’s physical, social and emotional needs. A relative visiting the home said that the matron of the home had visited his mother to assess her needs prior to her being offered a place to move into the home. Care staff told the inspector that when person is admitted to the home they have sufficient information to care for that person and meet that persons needs. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. The home ensures that each resident’s plan is reviewed regularly. The plan is updated to reflect any personal, health or social care changes. The home works to an efficient medications policy and procedures that protect the health and wellbeing of those living at the home. The aims and objectives of the home reinforce the importance of treating residents with respect and dignity. EVIDENCE: Care plans were sampled for four service users. Care plans are personalised, detailing the action needed to meet the health, personal, social and emotional care needs of the person living at the home. Plans are reviewed monthly and revised as needed to reflect the current care needs and support required by the person. There is documentary evidence that some service users are involved in the development of their care plans. Conversations with staff and residents suggest that changes in care are discussed with residents. There are risk assessments for moving and handling, nutrition and tissue viability. The results of these are incorporated into the individuals care plan. All residents are registered with a local GP service through which they access the Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 10 multidisciplinary health care team. Residents spoken with said that the staff at the home contact their GP’s promptly when they are unwell. Care staff working at the home said the same. Detailed records are kept of all contacts the resident has with health care professionals. An anonymous complaint received by the commission detailed concerns about the management of continence. Residents are assessed by a specialist nurse about their continence needs; this is recorded in the resident’s documents. The advice that is given is reflected in the care planning process. Several staff members have received training about the promotion of continence. During the two visits to the home there were no unpleasant odours that could be indicative of poor management of continence and residents were observed being assisted to the bathrooms to use the toilets. Medication administration record (MAR) sheets were seen for four service users. There were some signatures omitted from the records leaving it unclear as to whether service users had received their medications. But the deputy matron had highlighted these gaps and was in the process of addressing this issue. She said that she regularly checks the MAR sheets and raises any concerns she has noted with staff members. A trained nurse administers all medications at the home. It was observed that the process of administering medications is done in a safe manner. Medications are stored in secure cabinets in a clean and orderly fashion. The ordering and receiving of medications is documented. A copy of the Royal Pharmaceutical guidelines for the administration of medications in care homes is available at the home. No service users at the home presently administer their own medications. Staff members were observed giving support to residents in a sensitive and friendly manner. Residents spoken with said that the staff are friendly, nice and caring and will generally go out of their way to help you. Staff knock on residents doors before entering their rooms; this was observed and confirmed during conversations with residents. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. The home considers the views and interest of residents when planning the routines and activities at the home. The practices and attitudes of the staff team give residents the opportunity to remain as independent as they can be. Visitors are welcome at any time, residents can chose to entertain them in their own rooms or lounge or garden areas. Food is considered to be highly important and meal times are considered to be a social occasion. The menu is balanced and nutritious contributing the wellbeing of those living at the home. EVIDENCE: Information is obtained during the assessment process and development of care plans about a persons past and present interests. This helps in the planning of activities for the residents. A member of the care staff is allocated to be responsible for activities in the lounge area every the afternoon. These vary from organised events such as entertainers visiting the home to ball games, manicures, sing a longs, and reminiscence games. Residents said that they are given the choice whether they wish to join in with activities and that staff members respect their choices. Information about visiting entertainers is displayed on the notice board in the entrance to the home. The deputy manager said that for those residents that are too unwell to go to the lounge certain activities are done with them in their bedrooms such as pet therapy Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 12 and manicures or just a member of staff spending time chatting with them. For those residents that wish to outings are arranged to theatres and teashops. One resident said spoke of how much she enjoyed these outings. A record is kept by staff of the activities provided and who has taken part in them along with any comments about the response by residents to the activity. But this record has not been kept up to date. It is recommended that this record is kept up to date so that the home can assess the suitability and response of residents to the offered activities. Residents are able to receive visitors at any time and can choose where to receive their visitors. Two visitors said that they are able to visit at whatever time they want to, and that the staff members always make them feel welcome. Residents that are able to can access community facilities independently. One resident frequently takes a taxi to the local shopping centre and until recently was able to drive his own car to the shopping centre. A complaint had been received by the commission indicating that the food provided at the home is poor. The menu plan provided by the service prior to the site visit indicated that a varied nutritious diet is offered to all residents, but no choice was stated for lunch or teatime. Those residents spoken with all expressed their satisfaction with the quality of the meals. The cook or care staff discuss the menu of the day with them from which they are able to choose whether to have what is on the menu or choose an alternative meal. On the day of the visit the alternative meal was a salad that was taken up by several of the residents. A record is kept of the meals taken by the residents. Residents are able to choose where to take their meals, though they are encouraged to take lunch and tea in the dining room. Residents spoken to say that they could take their meals in their bedrooms if they wished to. A lunchtime was observed. Assistance with meals is given to those that require it with sensitivity. Residents sit at tables in friendship groups that creates a friendly sociable environment to take their meals in. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. Residents and others associated with the home demonstrate a good understanding of how to make a complaint and are confident that their concerns will be addressed promptly. Residents are protected from the effects of abuse by a work force that has a clear understanding of the issues about the protection of vulnerable adults. EVIDENCE: A robust complaints procedure is in place. Residents spoken with were able to say which staff members they would address any concerns or complaints to and that they are confident that concerns raised would be dealt with appropriately. A relative visiting at the time of one of the visits to the home was able voice his confidence that the home will respond to concerns and complaints promptly. A log is kept all complaints received by the home and with the actions taken to resolve the complaint. The provider discussed that the home views complaints as one of many ways of ensuring the service provided is maintained at a good standard and continues to improve. The complaint received by the commission was discussed with the provider. She expressed her disappointment that the person had not used the home’s complaints procedure to voice the complaint. During the course of the site visits evidence was seen that the service is meeting the regulations that the complaint suggested were not being met. Adult protection policies are in place and two members of staff have received training to enable them to cascade training about the protection of vulnerable audits to the other staff members. It was noted in the pre inspection information received from the home that the cascading of information had not Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 14 happened. The provider and deputy matron discussed that due to time constraints this training had not happened. But instead they had booked an external specialist to train staff members in the area of adult protection. Discussing with several care staff members evidenced that although formal training has not been received about the protection of vulnerable adults, in fact they are aware of the issues surrounding vulnerable adults and the action to take if they suspect an act of abuse has occurred. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. Residents live in a home that has a well-maintained environment, which provides aids and equipment to meet their needs. The well being of those living at the home is protected by good hygiene and infection control practices. EVIDENCE: The home is situated in a quiet area outside of Totton. The home comprises of a large building and separate smaller building known as the coach house. There are thirty-three rooms in total, twenty single rooms and seven double rooms. All rooms have hand-washing facilities and twenty-eight have en suite facilities. A large lounge and separate dining room is available in the main building and a lounge/dining area in the coach house. Residents living in the coach house are able to use the lounge and dining room in the main house. Sufficient toilet and assisted bathing facilities are provided in both houses. There is a large garden area that has seating. Several residents were making use of the garden when the inspector visited the home. They spoke of how they enjoyed being able to Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 16 sit outside, viewing the countryside and watching the birds and wildlife that enters the garden. The home was clean and free from offensive odours on the days the inspector visited. Residents said that the home is kept clean and tidy. A team of cleaning staff is employed for this purpose. Resident’s bedrooms looked clean and cheerful, many of them having personal items such as pictures, ornaments and some furniture. A musty smell was apparent in bedroom 3; the deputy matron said that there had been a water leak in this room that week and the room was still being attended to following that. All laundry is done in the home’s own laundry. This is kept clean and tidy. Suitable hand washing facilities are provided for staff and the residents, protective equipment such as gloves and aprons are readily available for staff members. Several staff member have attended courses about the control of infection and further training is planned. A complaint received by the commission had indicated that rooms in the home smell and in summer there are lots of flies in some of the rooms. During the site visits there was no evidence to support this complaint. Work has commenced on an extension for the home. The work is being managed effectively to have no impact on the residents. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. Rotas show well though out and creative ways of making sure the home is staffed efficiently, with particular attentions to busy times of the day ensuring that there are enough staff to meet the needs of those living at the home. Robust recruitment procedures are followed ensuring that resident’s wellbeing is protected. The service ensures that all staff within it’s organisation receives training focussed on improving the outcomes for those living at the home, using external agencies to provide the training if the service has not the skills to deliver the training. EVIDENCE: The staff rota evidenced that on a morning shift 2 nurses and 5 care staff are on duty, in the afternoon 1 nurse, 4 care staff and 1 care staff doing a 4pm till 8pm shift. At night there is 1 nurse, 3 care staff and 1 care staff doing a sleep in duty. The sleep in member of staff is awake until 11.30pm to help settle the residents and is awake at 6am to assist with the early morning work. There are separate cleaning, laundering, and cooking and gardening staff rostered to fulfil these roles. Staff said that generally there is enough staff to meet the needs of people living at the home; residents that the inspector had conversations with also expressed this. One resident said that it sometimes took a long time for the call bell to be answered. This was not an experience expressed by other service users, nor was this situation observed during the two visits to the home: call bells were noticed to be answered promptly. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 18 Monthly dependency scores of the needs of the residents are made. The deputy matron said that these details are used to influence staffing; with the provider supporting increased staffing numbers when the dependency levels increase at the home. A complaint received by the commission suggested that there are not enough staff at the home to meet the needs of the residents and that if staff spend time with service users not attending to personal needs they are made to feel like they are ‘shirking’. It was observed that staff spend time talking with the residents and attention is paid to meeting residents social and emotional needs as well as their personal needs. The deputy matron and provider said that although the home is busy and many of the residents need a lot of personal support they encourage staff to spend time talking with the residents. No evidence could be found to substantiate this complaint. At present 32 of the care work force have an NVQ level 2 or above in care. The provider spoke of her commitment to support care staff through NVQ training and indicated that a number of care staff are due to start the NVQ training eminently. Robust recruitment procedures are in place. Sampling four staff member’s files evidenced that recruitment procedures are followed. This includes ensuring two satisfactory references and a satisfactory CRB clearance are received before a person commences employment at the home. Training records indicate that staff receive mandatory training such as fire safety, moving and handling and for those that handle food food safety training. Other training that staff members have received includes administering medications in care homes, first aid, nutrition and the older person, infection control and dealing with challenging behaviour. Staff spoken with said that they receive the training they need to fulfil their role. Discussion with residents did not reveal any concerns that staff might not have the skills to care for them. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality outcome in this area is good. This judgment has been made using available evidence including a visit to the service. The management team work effectively to continuously to improve the service and provide an increased quality of life for the service users. There is strong ethos of being open and transparent in all areas of the running of the home. The service responds to suggestions by service users, their representatives and staff members that they utilise as part of the quality auditing of the service. But audit is not enhanced by completion of quality audit documents. Clear procedures protect resident’s finances. The home has a good record of meeting relevant health and safety requirements and legislation. EVIDENCE: There has been no change to the management structure at the home since the last inspection. During the two site visits the matron was on leave. The staffing structure and empowerment of staff allows the absence of the matron to have Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 20 no adverse effect on the running of the home. One of the registered providers, Mrs Collins is responsible for the financial, administration and refurbishment of the service and is present at the home on most days. All staff are aware of the roles and responsibilities of the registered provider, the matron and the deputy matron. Staff expressed satisfaction with the management of the home and the support given to them by the management team. Staff said that they are able to put forward ideas about the running of the home that are considered and acted upon if possible. Staff meetings are held. Minutes from these indicate that comments from staff members are acted on. The home follows the registered nursing homes programme for quality assurance of the service. But entries in the audit document indicated that minimal work had been done on it since 2004. The provider said that service users opinions about the running of the service are gathered during one to one conversations with residents. The registered provider is not documenting monthly reports about the quality of the service being provided; the registered provider told the inspector that this will now be done. But it is evident through discussions with the provider, deputy matron, staff members and residents that the service is continually being reviewed and measures being put in place to improve the quality of the service. The home does not look after any service users monies. All financial costs incurred are billed directly to the representative who is responsible for that person’s money if it is not the service user. Facilities are available in bedrooms for residents to keep their money in a secure place. Polices and procedures are in place about health and safety issues. The fire logbook indicates that all staff receives fire safety training at least twice a year. Fire risk assessments are in place and have been revised to accommodate the building work in place. The altered fire escape plans are displayed in the entrance hall of the home and have been discussed with all staff and residents. Fire safety checks are performed at the fire and rescue services recommended intervals. A food safety inspection by the environmental health office was performed in April 2005; the service has acted on the recommendations given at this inspection. During the visits to the home the kitchen was clean and tidy, food stuffs stored in an appropriate manner, a record was available of hot food temperatures, fridge and freezer temperatures and staff entering the kitchen were wearing appropriate clothing. A sample of records was seen evidencing that services and equipment are serviced at the manufacturers recommended intervals. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard OP12 OP33 Good Practice Recommendations The registered person should keep a record of the activities attended by service users as a method of assessing the suitability and effectiveness of activities. The registered provider should ensure that any qualityauditing programme that the home uses is completed within a timely manner. Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Colbury House Nursing & Residential Home DS0000011420.V303180.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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