Inspection on 14/11/05 for Colindale Care Home

This inspection was carried out on 14th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 01/08/06

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 Debra Jones Unannounced Inspection 14th November 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 Colindale Care Home DS0000003941.V266132.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. Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 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.V266132.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to four residents above the age of 55 at any time. 27th July 2005 Date of last inspection Brief Description of the Service: Colindale Care Home is a large 1920s detached house that was converted for use as a residential home. It is located in a quiet residential area of Winton, 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. 14 people are now accommodated there after substantial redevelopment and the name has changed to Colindale (following the closure of the sister home formerly known as Colindale). Bedrooms are now 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.V266132.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over an hour and a half on the 14 November 2005 and was the second of the two anticipated inspections of the year. The inspection focused on the core national minimum standards that had not been assessed at the previous inspection this year. No follow up was needed from the last inspection as no requirements or recommendations had been made. The Inspector looked around some of the building and at some records. The owner/ manager – Jane Hart and Ian Gray – Business Manager and Head of Human Resources were spoken to, along with staff on duty at the home. Communication with most residents is fairly limited. The Inspector joined some residents in the lounge as they were updating their day / date / season / weather board. At the time of the visit 14 people were living at the home. Prior to the inspection a number of comment cards were sent out by the home on behalf of the Commission. Of those returned 2 were from Doctor’s surgeries and 4 from relatives / visitors. All comment cards returned were very positive about the staff and service provided at the home. One GP said ‘excellent home. No problems.’ ‘I always get a friendly welcome. The home is always clean and so is my friend. She always looks well cared for. I am very happy with her care.’ A visitor. ‘I am pleased with the care and attention my friend receives at the home. The staff are always very friendly.’ Another visitor. What the service does well: Colindale provides a service for older people with dementia and long term mental disorders in a well-decorated and comfortably furnished house. The home has a warm and relaxed atmosphere and residents are clearly at ease. Medication is generally well managed and residents can have confidence that staff look after their medicines well and administer them properly. (Some recommendations are made to further improve practice.) Visitors are made welcome at the home and some residents go out of the home on trips with their families and friends. Some enjoy support from the Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 6 local church. When residents have been very unwell their families have been able to stay with them. Staff have a good understanding of adult protection which helps protect residents from abuse. Colindale is well organised and well managed by people with the skills, knowledge, qualifications and experience necessary. The home safeguards the financial interests of residents by not being involved in their affairs. They do not currently hold any money or valuables belonging to them. What has improved since the last inspection? What they could do better: The home is always looking to improve the service they deliver at the home. They are continuing to upgrade the environment and are about to start refurbishing the kitchen. To further improve practice in respect of looking after the residents’ medicines and to make the system is as free from risk as possible the home should consider introducing the following:_ • Sample signatures of staff who administer medicines should be kept on the medication file. • It would be good if the home stored their medication in a metal cabinet. Where medicines have to be stored in the fridge it would be good if the home had a plastic lockable box to keep them in rather than a metal one. • Where medicines are not in the blister packs it would be good if there was a system in place so you could easily tell how much medication should be in the home i.e. a recent reference point such as a record of the date a new pack is started either on the pack or on the MAR chart, or a carry forward balance on the MAR chart to provide an audit trail. • Medication Administration Records should include information about any allergies that residents have. The adult protection policy must be updated to acknowledge the introduction of the Protection of Vulnerable Adults list. This is the list that unsuitable staff can Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 7 be referred to and which has to be checked before anyone starts work in a care home. The home needs to have a quality assurance system in place and to write an annual report of what they have found out about the quality of the service they have provided in the last year and how they are going to improve their service to residents in the following year. 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.V266132.R01.S.doc Version 5.0 Page 8 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.V266132.R01.S.doc Version 5.0 Page 9 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): (Standards 1, 3 and 5 were met at the last inspection. 6 does not apply.) These standards were not assessed on this occasion. EVIDENCE: Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 10 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): 9 (Standards 7, 8 & 10 were met at the last inspection. 7 & 10 were exceeded) The medication at this home is generally well managed promoting the good health and well being of residents. EVIDENCE: Medication at Colindale is only administered by staff who are well trained and confident in carrying out this task. Currently there are no sample signatures of staff who administer medicines on the medication file. Where it is recommended that 2 staff sign to confirm balances of certain medicines this was seen to be happening. Medication is tidily stored in a cupboard that is not made of metal. A system for returning medicines was in place and clearly in regular use. Residents’ medication is appropriately and regularly reviewed. The records agreed with the audit trail for medicines that the pharmacy provided in MDS blister packs. For some other medicines (not in the blister Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 11 packs) there was no recent reference point such as a record of the date a new pack is started either on the pack or on the MAR chart, or a carry forward balance on the MAR chart to provide an audit trail. Medication Administration Records did not include information about any allergies. Plans are in place to refurbish the area that medicines are kept in. This would include the installation of a metal medicine cabinet. No medicines in the home currently need to be kept in the fridge i.e. medicines that might need to be stored at a lower temperature. The home has a thermometer that records the maximum and minimum temperature of the fridge used to store medication. The home is amenable to obtaining a plastic lockable box, to store medicines in the fridge, to replace their metal one. Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 12 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): 13 (Standards 12, 14 and 15 were met at the last inspection.) Residents’ lives are enriched by the social opportunities afforded by their visitors. Visitors are made welcome at the home and can come whenever it suits the residents. EVIDENCE: Information is given to residents and their relatives / friends about staying in contact and visiting the home. In the lounge there was talk of how one resident had enjoyed a trip out with their family at the weekend and during the inspection another resident was getting ready to go out with their visitor. Comment cards returned to the Commission from relatives / visitors confirmed that they felt welcome when they visited. Residents are able to see their visitors in the lounge, dining room or their own rooms as they wish. Ms Hart talked of how when one resident had been very unwell recently her family had stayed in the upstairs quiet lounge. The visitors’ book confirmed the number and range of visitors to the home e.g. General Practitioners, District Nurses and Chiropodists. The local church also supports some residents. Colindale Care Home DS0000003941.V266132.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): 18 (Standards 16 and 17 were met at the last inspection.) The home’s adult protection policy demonstrates the homes commitment to understanding abuse and of protecting residents. Ensuring that all staff have an understanding of adult protection matters makes residents even safer in the home. EVIDENCE: An adult protection policy and information about abuse is available to staff in the home. This policy has not been reviewed / updated since the introduction of the Protection of Vulnerable Adults List, held by the Department of Health, in July 2004. Since that date the home has not had to make any referrals of unsuitable staff to that list. As part of the recruitment procedure new staff are checked against the protection of vulnerable adults list before they start work. No concerns about adult protection have been raised at the home. Most staff have had adult protection training and there is a course planned for all staff at the home for January 2006. Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 14 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): (All these standards were met at the last inspection.) EVIDENCE: These standards were not assessed on this occasion. However, it is noted that since the last inspection further improvements have taken place to the premises. A walk in shower has been installed in the first floor bathroom. Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 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): All these standards were met at the last inspection with 27 and 28 exceeded.) These standards were not assessed on this occasion. EVIDENCE: Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 16 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 (Standard 38 was met at the last inspection and 37 was exceeded) The home is well managed and organised by people who have the skills, knowledge and experience to run the home. Whilst there is nothing to demonstrate that the home is not run in the best interests of residents a full quality assurance system has not been fully implemented yet. EVIDENCE: Jane Hart is an experienced proprietor / manager and actively works alongside her staff in the home in the direct care of residents. Ms Hart is a qualified ENM and her registration on the nursing register remains live. She has also obtained the Registered Manager’s Award. Ms Hart attends training courses with her staff at the home. Ian Gray works alongside her as the Business Manager and Head of Human Resources. He has an NVQ level 4 in administration. Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 17 In previous years the home has depended on feedback from Commission surveys to find out what stakeholders outside the home think of Colindale. They have handed out their own questionnaires but have had no response. Apart from this the home has information that could be used in a quality assurance report e.g. thanks and compliments; information about complaints; plans for the improvement of the home; availability of CSCI inspection reports for residents, families and prospective residents and their families; up to date policies and procedures. For the first time in early 2006 the home plans to write a quality assurance report based on the analysis of all the above information and the results of any surveys carried out between now and then. This report can then be circulated to any interested parties – including the Commission. The home is not involved in the financial affairs of residents and they do not currently hold any money or valuables belonging to them. Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 18 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 4 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 2 x 3 x x x Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 19 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 OP18 Regulation 13 Requirement The adult protection policy must be updated to include information about POVA (Protection of Vulnerable Adults) list i.e. referring staff to it when required and checking it prior to employment. Timescale for action 01/01/06 Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Medicines should be kept in a metal cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973 and those kept in the fridge should be stored in a locked plastic box. The home should follow guidance from the Royal Pharmaceutical society in “The Administration of medicines in Care Homes and Children’s Services”: • The home should have a clear audit trail for medicines not in MDS blister packs e.g. by recording when a new container is started or a carry forward balance on the MAR chart. Medication administration records should include information about any known allergies. It is recommended that results from quality assurance information collected be analysed and a report be compiled. 2. OP9 3. 4. OP9 OP33 Colindale Care Home DS0000003941.V266132.R01.S.doc Version 5.0 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.V266132.R01.S.doc Version 5.0 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. 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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