Inspection on 21/10/05 for Colbury House Nursing & Residential Home

This inspection was carried out on 21st October 2005.

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.

Other inspections for this house

Colbury House Nursing &... 12/02/08

Colbury House Nursing &... 11/07/06

Colbury House Nursing &... 24/05/05

Colbury House Nursing &... 15/12/04

Colbury House Nursing &... 13/05/04

Colbury House Nursing &... 04/02/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Colbury House Nursing & Residential Home Hill Street Totton Southampton Hampshire SO40 2RX Lead Inspector Marilyn Lewis Unannounced Inspection 21st October 2005 09:30 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.V253625.R01.S.doc Version 5.0 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.V253625.R01.S.doc Version 5.0 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 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.V253625.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 17 beds may be used at any time for service users who are only in need of personal care 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 24th May 2005 Date of last inspection 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 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. 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. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on the 21st October 2005. The inspector toured the home and met with nine residents and four staff members. Care plans were sampled for three residents and records were seen for medication, complaints, staff training, staff recruitment, fire safety and fire drills and the maintenance and servicing of equipment. The service users at the home prefer to be known as residents and this is respected in the writing of this report. The registered manager of the home Christine Harris, is known at the home as the Matron and this title is used in this report. This inspection is the second unannounced inspection for the year 2005/2006. Information on the standards assessed in the first inspection can be found in the inspection report dated 24th May 2005. What the service does well: On the day of the inspection the home looked clean, homely and welcoming. Residents are provided with a written contract giving the terms and conditions for living at the home. Good care plans provide staff with the information required to fully support the residents. Residents are protected by the home’s procedures for dealing with medicines. Residents are able to exercise choice and control over their daily lives. Residents can choose to participate in a variety of suitable leisure activities, can receive visitors as they wish and enjoy a choice of nourishing meals. Residents know that all complaints will be taken seriously and investigated. Residents are protected by staff awareness of the procedures to be followed should abuse be suspected. The home provides a clean, safe environment, with large gardens, cheerful communal rooms, personalised bedrooms, specialist equipment as required and sufficient bathroom and toilet facilities. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 6 Residents’ care needs are met by the sufficient number and skill mix of staff employed at the home, and are protected by the home’s recruitment procedures. The registered manager has the qualifications and experience necessary to run the home and residents benefit from her open approach to management. Residents’ financial interests are protected by the home’s clear financial procedures. Residents are protected by the regular supervision of staff. 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.V253625.R01.S.doc Version 5.0 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.V253625.R01.S.doc Version 5.0 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): 1 and 6 Residents are provided with a written contract clearly stating the terms and conditions for residency at the home. The home does not provide intermediate care. EVIDENCE: Each resident is provided with a written contract that gives details of the terms and conditions for living at the home. The contract states what services are included in the fees and services provided at an additional cost, such as hairdressing. The home does not provide intermediate care and therefore standard 6 does not apply. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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 and 9 Good care plans provide staff with the information they need to fully support the residents, who are protected by the home’s clear procedures for dealing with medicines. EVIDENCE: Care plans were sampled for three residents. The care plans were detailed providing good information for staff to fully support the residents. Risk assessments had been completed and risks identified were reflected in the care plans. Residents’ likes and dislikes for participating in daily living activities, such as the time they wished to get up and go to bed were recorded. The care plans showed evidence of regular review and the involvement of the resident or their relatives. The home has clear procedures in place for dealing with medicines. Medication charts seen had been completed appropriately. GPs review the medicines regularly and confirm the use of homely medicines for individual residents. At the time of the inspection there were no residents who were prescribed Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 10 controlled medicines. There were also no residents who were administering their own medication. Written permission was seen to crush medication for one resident. New procedures were in place for the recent changes in the method of disposing of medication. The registered matron said that medication was kept in the home for at least seven days following the death of a resident. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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 and 15 Residents are able to choose to participate in a variety of suitable leisure activities, can receive visitors as they wish and enjoy a choice of nourishing meals. EVIDENCE: Residents’ hobbies and leisure interests were recorded in their care plans. The home does not employ an activities co-ordinator, however, staff provide a suitable programme of activities for the residents. Activities available include bingo, music and movement and crafts. On the day of the inspection, staff were involved in a reminiscence session and arrangements were underway for a Halloween party. Earlier in the week some residents had gone with staff on a shopping trip to Southampton. During the inspection transport arrangements were being made to take some residents to a concert in Lyndhurst in November. The matron said that there were no restrictions on visiting times and this was confirmed by two residents who said that their visitors were able to come at any time and were always made to feel welcome by staff. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 12 Residents’ participation in social activities was recorded in their daily records. The records seen indicated that residents were also able to spend time quietly in their room if they wished. One resident said that she appreciated being able to do what she wants, joining with others or spending time on her own. Residents are able to choose where they take their meals and are offered a choice of nourishing meals. On the day of the inspection lunch served was faggots with potatoes, carrots and peas or savoury mince, followed by treacle sponge and custard. The cook said the menu for tea was soup, quiche, beans and bread and butter, with cake and yoghurt for dessert. The home caters for special diets including diabetics and vegetarians. Five residents spoken to at lunch said that they enjoyed the food provided at the home. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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 and 18 The home has clear procedures in place for handling complaints and residents know that any complaints will be investigated. Residents are protected by staff awareness of the home’s procedures to be followed should abuse be suspected. EVIDENCE: The home has a complaints policy in place that indicates who will investigate and timescales for the process. Some complaints records are kept on the computer system. The records seen stated who was reporting the complaint, actions taken and the outcome. The matron said that each resident was provided with a copy of the complaints procedures and every staff member was also provided with a copy when commencing work at the home. The procedures stated that the Commission could be contacted if the complaint remained unresolved following investigation at the home. The matron changed the wording of the procedures to state that the Commission can be contacted at any time and she arranged for an up to date copy to be given to all concerned. Two residents spoken to about the complaints procedures knew how to make a complaint. Both said that they had no concerns or complaints about the care provided at the home but felt that any matters raised would be investigated and acted upon. Clear procedures are in place for staff to follow should abuse be suspected. Leaflets from Hampshire County Council about abuse issues were available to Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 14 residents, staff and visitors to the home. Staff receive training in the protection of vulnerable adults. Two staff members spoken to during the inspection were aware of the procedures to be followed should abuse be suspected and indicated that they would have no hesitation in reporting any concerns. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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): The provision of a clean, safe home, with large gardens, cheerful communal rooms, personalised bedrooms, specialist equipment and sufficient bathroom and toilet facilities, gives a pleasant environment for all those who live and work there. EVIDENCE: Colbury House Nursing and Residential Home is situated in quiet area of Totton, close to the New Forest. The home comprises of a large detached property and a smaller detached property, known as the Coach House. There are thirty three rooms in total, twenty six single rooms and seven double rooms. All of the rooms have washing facilities and twenty eight have full ensuite facilities. Thirty one residents are accommodated in the main house and nine can be accommodated in the Coach House, although at present one double room in the Coach House is being used as a single room. A large lounge and separate dining room is provided in the main house and a lounge /dining room is available to residents in the Coach House. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 16 Residents accommodated in the Coach House have access to the lounge and dining room in the main property. Sufficient bathroom and toilet facilities are provided in both properties. The home is set in large gardens and there are very pleasant views of the surrounding countryside. A variety of seating is available on the patio area. Residents’ rooms looked clean and cheerful and contained many personal items such as pictures and ornaments. All bedroom, bathroom and toilet doors have suitable locks fitted, allowing residents privacy when required. Three rooms in the main house had steps up from the main corridor. The matron said that residents accommodated in the rooms did not require the use of specialist equipment such as hoists. The steps would make the use of such equipment difficult. Specialist equipment including hoists, pressure relieving mattresses, glide sheets and stand aids are available for residents assessed as requiring it. The upper floor of the home is used for administration purposes and is not accessed by residents. All areas of the home seen during the inspection, looked clean and well maintained. Protective clothing such as disposable gloves and aprons was readily available for staff. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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 and 30 Residents’ needs are met by the sufficient number and skill mix of staff employed at the home. Residents are protected by the home’s recruitment procedures and staff training programme. EVIDENCE: The home employs the matron, eleven trained nurses, two senior carers and eighteen carers. Separate staff are employed for administration, catering, laundry, domestic and maintenance duties. The registered provider Mrs Collins works closely with staff at the home. Rotas seen indicated that a sufficient number and skill mix of staff were on duty. One carer is allocated the responsibility for providing the care for residents in the Coach House, assisting them with personal care as required. Four care staff members hold NVQ level 2 or above and six more are in the process of completing the qualification. At the time of the last inspection, records seen for three staff members did not contain all the information required in Schedule 2 of the Care Homes Regulations. These staff members have since left the home. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 18 Records seen for five staff members on this occasion contained all the information required including two written references and full employment histories. Criminal Records Bureau (CRB) checks had been completed for four of the staff members and the (CRB) check was awaited for the fifth person, although the home had received a Protection of Vulnerable Adults (POVA) First check. Staff receive training in core skills including moving and handling, infection control, food hygiene and in specific topics relevant to the service such as Diabetes. All new staff members complete an induction programme that covers all aspects of care provision. A trained nurse and three carers spoken to during the inspection said that they were encouraged to attend training sessions. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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, 32, 33, 35, 36 and 38 The registered manager has the qualifications and experience necessary to run the home and residents benefit from her open door approach to management. Residents’ financial interests are safeguarded by the home’s financial procedures and they are protected by the regular supervision of staff. The lack of clear fire safety and fire drill records could result in some staff not receiving the training and practice required, which could put residents safety at risk. EVIDENCE: The matron is the registered manager of the home. Christine Harris is a trained nurse who is due to complete the Registered Managers Award later this year. She is supported in her role, by the registered providers, particularly, Mrs Collins, who is involved in the day to day management of the home. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 Page 20 The matron operates an open door approach to management and it was noted during the inspection, that there was a relaxed, friendly atmosphere in the home. Three staff members spoken to during the visit said that they received support and encouragement from the matron and Mrs Collins. Staff meetings are held regularly and records of the meetings are distributed to staff members. The matron said that resident and relative group meetings were not held but one to one meetings took place frequently. Twice a year a survey is conducted using questionnaires to obtain the views of residents and their relatives on the quality of care provided at the home. Mrs Collins said that when residents are admitted to the home she provides relatives with her mobile telephone number so that they can contact her if they wish. The home does not hold any money for residents. Any expenses, such as hairdresser bills, are invoiced directly to the resident, their relatives or their solicitor responsible for their financial affairs. Staff receive regular supervision. The matron supervises the trained nurses who in turn supervise the care staff members. Staff who supervise have been given guidance on the supervision process. Supervision covers all aspects of care, plus training and any areas of concern. During the inspection visit the kitchen looked clean and in good order. Food was stored appropriately and the temperatures of the fridges and freezers were monitored and recorded. Hazardous substances such as cleaning fluids were stored securely. Records seen indicated that the lift and specialist equipment such as hoists were checked and serviced as required. Records for staff fire safety training and fire drill practice were unavailable for 2005 and it was therefore not possible to confirm that all staff had received training and attended fire drills. Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 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 3 3 3 3 3 3 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 3 3 x 3 3 x 3 Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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. 1 Standard OP38.2 Regulation 23(4)(d) (e) Requirement The registered person must ensure that all staff receive fire safety training and attend fire drills. Records for fire safety training and fire drills must be kept available at the home at all times. Timescale for action 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Colbury House Nursing & Residential Home DS0000011420.V253625.R01.S.doc Version 5.0 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.V253625.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!