Inspection on 01/08/06 for Colindale Care Home

This inspection was carried out on 1st August 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.

Other inspections for this house

Colindale Care Home 03/04/08

Colindale Care Home 14/11/05

Colindale Care Home 27/07/05

Colindale Care Home 27/01/05

Colindale Care Home 04/06/04

Similar services:

Fairfields Country Rest Home

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Fairfax House

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

CARE HOMES FOR OLDER PEOPLE Colindale Care Home 1 Richmond Park Avenue Charminster Bournemouth Dorset BH8 9DL Lead Inspector Martin Bayne Key Unannounced Inspection 08:45 1st August 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 Colindale Care Home DS0000003941.V306765.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. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colindale Care Home Address 1 Richmond Park Avenue Charminster Bournemouth Dorset BH8 9DL 01202 514733 01202 258817 ian@colindalecarehome.wanadoo.co.uk 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) Mrs Jane Hart Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (14) Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to four residents above the age of 55 at any time. 14th November 2005 Date of last inspection Brief Description of the Service: Colindale Care Home is a large 1920s detached house that has been converted for use as a residential home. It is located in a quiet residential area of Charminster, within easy walking distance of a local park with a bowling green and cricket pitch. Local amenities include shops, a post office, restaurants, cafes and places of worship. A bus route to Bournemouth town centre is readily accessible. The home until recently was known as Four Seasons and provided care for up to 10 people. The home now has a registration for 14 people after substantial redevelopment and the name changed to Colindale (following the closure of the sister home formerly known as Colindale). Bedrooms are located on the lower ground, ground, first and second floors of the home. All service users have single rooms. Some have en suite facilities. The premises are centrally heated. Communal facilities consist of a separate lounge and dining room and a quiet room on the first floor. Outside there is a large patio area at the rear of the building with a raised grassy area. The summerhouse is used as an office for the Business Manager and Head of Human Resources. Colindale Care Home is a specialist home providing care and support for older people with enduring mental health problems and dementia. The home is accredited as being family friendly and staff often bring their children into the premises adding to the feeling of being in a family home. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of the home that took place between 8.45am to 2.30pm. The aim of the inspection was to evaluate the home against the core standards for older people and to follow up on the requirement and four recommendations made at the previous inspection. The registered manager was not available on the day of inspection. The inspector was assisted by the Business Manager and the Head of Care throughout the inspection. The inspector was shown around the home and was introduced to the residents. Some of the residents were spoken with, however due to their mental frailty they were not able to provide an account of what it was like to live in the home. One relative who was visiting the home was spoken with. Records required to be kept available in the home were viewed and a sample of three residents’ files was used to track this paperwork throughout the inspection. The fees for the home range from £461 to £525 per week. What the service does well: 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. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 6 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 Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 7 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 Residents benefit from a full assessment of their needs being undertaken before they are offered a place at the home. EVIDENCE: Throughout the inspection a sample of three residents personal files were used to track the required paperwork that the home must maintain. Two of these residents were admitted since the time of the last inspection. Mrs Hart, the Registered Provider was found in each case to have carried out a preadmission assessment prior to the person being offered a place at the home. The assessments were recorded on a form used by the home and covered all of the topics detailed within the standards. Where residents are referred through Social Services, a copy of the care management assessment is obtained. Prospective residents are visited by Mrs Hart from where they are referred as part of the assessment where possible and relatives are invited to the home. The home does not provide a service for intermediate care. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 8 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 Residents’ health needs are met at the home with their privacy and dignity maintained. Medicines are administered safely. Care plans and risk assessments are carried out as part of the process of meeting residents’ needs. EVIDENCE: Care plans had been developed for all three residents tracked through the inspection through the assessment process. A main copy of the care plan is kept in the office and one is kept in the ‘Kardex’ together with a summary of the person’s daily routines. A copy of the daily routines is kept in the resident’s room so that this key information is available to the staff. Risk assessments that link to care planning were also found to have been carried out for appropriate needs. The system ensures that these are ‘working documents’ for use by the staff. The returned comment cards for residents spoke of the high standards of care in the home. Some of the residents were spoken with during the inspection, however due to their mental frailty they were not able to give an account of what life was lie in the home. During the inspection one relative was spoken with who said that the standards of care in the home were of a high standard. From the care plans there was plenty of evidence that health needs of residents were being met at the home. Each resident is registered with a GP Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 9 and there was a record that medical assistance had been sought appropriately. The home has good links with the district nurses and the community mental health team. There was again evidence from the records that the home worked in partnership with these agencies in meeting needs of residents. The home uses a unit dosage system for administering medicines to residents. Due to the mental frailty of all of the residents, none are able to take responsibility for their own medicines. The medication cabinet is in the form of a locked cabinet in the kitchen. The inspector was informed that there were plans to refurbish the kitchen in the future and at this point a metal purpose built cabinet will be purchased as recommended. The person in charge of each shift takes responsibility for the keys to the medication cabinet and administering medication. The medication cabinet was inspected and medicines stored correctly. A recommendation made at the last inspection about the storing of medicines that require refrigeration had not been met as there was some confusion as to the container that the home should use. It was agreed that the home should store these medications in a plastic lidded box. The medication administration records for the residents were seen. It was recommended that the procedure for administering medications be changed to one where staff sign the medication administration records for each resident immediately after administration and not after medication has been administered to all of the residents. With respect to standards of privacy and dignity of residents, it was noted that each resident was wearing clean clothes with their hair and personal appearance tended to. Residents are washed and dressed in private and are changed into clean clothes if their clothes get dirty. The home tries to obtain a life history on each resident so that they get to know the persons’ likes, dislikes and personal habits and routines. With respect to standards of privacy and dignity residents, it was noted that each resident was wearing clean clothes, their hair and their personal appearance tended to. Residents are washed and dressed in private and are changed into clean clothes if their clothes get dirty. The home tries to obtain a life history on each resident so that they get to know the persons’ likes, dislikes and personal habits and routines. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 10 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 The home tries to meet the needs of residents in terms of their choice and preferences and to maintain as much choice and control over their lives as possible. Residents are supported to maintain links with families and friends. The home provides a good standard of food. EVIDENCE: Through the life histories obtained for each resident the home tries to meet the expectations and preferences for each resident. Both group and individual activities are arranged for the residents and recorded in the activities book. Light exercise sessions are run in the home and old time music is played for residents. One resident has visits from the local church, some residents enjoy the garden and one is supported with her knitting. The relative who was visiting informed that they were made welcome at the home. Visitors are requested to arrive after 10am and for residents to be back in the home by 7pm. Relatives returned positive comment cards on their experience of the home. On arrival at the home residents were having their breakfast in the dining room. The likes and dislikes of residents with regards to food were found to be recorded on the care plans together with any specialist diets. Nutritional assessments are undertaken with a record maintained of fluid and food intake should this be required. Many of the residents require a soft diet and Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 11 assistance with feeding and this is recorded within their care plans. The relative spoken with informed that the standard of food provided in the home was of a good standard. Records are maintained of food provided in the home, sufficient to know what each resident has eaten. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 12 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 Residents benefit from staff being trained in adult protection and their being a well publicised complaints procedure. EVIDENCE: Since the time of the last inspection there have been no complaints made to the management of the home and none have been brought to the attention of CSCI. The home has a complaints procedure that complies with the standards for older people and is displayed in the front reception area and also in the Service Guide. Relatives are given a copy of the Guide when a person moves into the home. Relatives are therefore well informed of how to complain. Due to the mental frailty of the residents, they rely on their relatives or visitors to complain on their behalf. At the last inspection a requirement was made that the home obtain a copy of the guidance published by the department of health on the protection of vulnerable adults. The home was found at this inspection to have obtained this document. Since the last inspection the home has dismissed one member of staff and put into effect the above guidance with this person being referred to the POVA list. Concerning adult protection training, staff are required to read the adult protection policies and procedures relating to the home before they start work. Additional staff training is offered to staff when courses are available. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 13 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 EVIDENCE: On the day of inspection the home was found to be clean and free from unpleasant smells. It was also found to be in good decorative order throughout. The home provides accommodation for the fourteen residents on four floors and there is no stair or shaft lift. It was recommended that this is clearly detailed within the Statement of Purpose as residents must be able to manage the stairs safely as part of the admission criteria for the home. Should a resident become too frail to manage the stairs safely, they are offered a room on the ground floor where there is access to the communal rooms and the assisted bath. During the inspection a tour of the building was made and a number of residents’ bedrooms were seen. It was evident that residents were able to bring their possessions to personalise their rooms. The majority of the radiators in the home are uncovered. The inspector was informed that each radiator had a thermostat fitted and this set to a maximum of 43 degrees thus ensuring a low surface temperature so no resident can get Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 14 burnt. The hot water outlets of the baths have thermostatic miser valves fitted to ensure that residents are protected from scalding water. It was noted that on the first floor, the taps in one of the communal bathrooms had been removed. It was explained that there had been a problem with a resident causing floods. A risk assessment had been carried out and recorded with this being the best way identified to stop the risk of flooding. With regards to infection control, all of the staff receive training and the home has policies and procedures. Gloves and protective clothing are available for the staff as well as alcohol gels. As the home has no sluice facility, there are policies and procedures for the cleaning of commodes. The home has a dedicated laundry room on the lower ground floor with washing machines that carry out a disinfection cycle. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 15 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 Residents needs are met through the current staffing levels and the staff are trained appropriately. Residents could be put at risk by POVAFirst checks not being carried out on some new staff. EVIDENCE: Staffing levels at the home remain the same as at the time of the last inspection with, 3 care assistants are on duty between 8am and 2pm, with one person working in the kitchen for part of this time and 4 care staff are on duty between 2pm and 8pm. Two awake care assistants are on duty at night. Records are maintained of who has worked each shift. Staffing levels at the time of the inspection reflected the above. With regards to NVQ training the home has now met the target of 50 of the care staff having NVQ level 2 or above. Through discussion about staffing at the home it was learnt that some part time staff had started working under supervision within the home before the POVAFirst check had been returned. The home has a record of good recruitment practice and the fact that these staff had started working was as a result of misunderstanding of the regulations. A requirement was made that these staff must not work in the home until their POVAFirst check is returned. All other requirement checks are undertaken. It was recommended that the staff application form be amended to reflect changes to the Regulations of July 2004. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 16 All new staff receive induction training that complies with the guidance of Skills for Care. Staff are given core training in moving and handling, fire safety, first aid, basic food hygiene and medication administration. Additional training is offered in adult protection, care of people with dementia, challenging behaviour and other relevant course. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 17 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 The home is well managed and run in the interests of the residents. Health and safety is promoted in the home. EVIDENCE: Mrs Hart is the registered provider for the home and is an EN-M registered nurse as well as having undertaken the Registered Manager’s Award. The home has a Business Manager, also trained to NVQ level 4 in administration and a Head of Care. The home was found to be well managed. The home was found to be run in the interests of the residents with the home receiving many letters of thanks regarding the care in the home. The home is not involved in the financial affairs of any of the residents and no money is held on behalf of residents. The fire logbook was inspected and it was found that tests and inspections of the fire safety system were being carried out to the required timescales. A Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 18 sample of other health and safety documents was also seen, such as tests on the portable electrical equipment wiring, the fire work place risk assessment, and certificates for the servicing of the gas boilers. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 19 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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 4 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 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 20 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 Staff must not be employed at the home until a POVAFirst check is returned and then under supervision until the return of a CRB. Timescale for action 07/08/06 1 OP29 Schedule 2 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 OP9 OP27 OP1 Good Practice Recommendations Medicines should be kept in a cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973 and those kept in the fridge should be stored in a lidded plastic box. It recommended that the staff application form be amended to reflect changes to Regulations in July 2004. It is recommended that the Statement of Purpose inform that the home does not have a shaft or stair lift. 1. 2. 3. Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Colindale Care Home DS0000003941.V306765.R01.S.doc Version 5.2 Page 22 - 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. 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