Inspection on 11/10/05 for College Hill

This inspection was carried out on 11th 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

College Hill 28/06/06

College Hill 13/04/05

College Hill 07/09/04

College Hill 22/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE College Hill 64/66 College Hill Road Harrow Weald Middlesex HA3 7HE Lead Inspector Richard Adkin Unannounced Inspection 11th October 2005 09:00 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 College Hill DS0000017528.V256485.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. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service College Hill Address 64/66 College Hill Road Harrow Weald Middlesex HA3 7HE 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) 020 8954 1235 020 8954 1668 Mrs Blasita Jeyarajah Mrs Blasita Jeyarajah Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th April 2005 Brief Description of the Service: College Hill is a care home providing personal care and accommodation for up to 11 older people. Mrs Blasita Jeyarajah, who is the registered manager of the care home, also owns the home. The registered care home is located within a short drive or several minutes walk from Harrow Weald High Road. Harrow Weald has a variety of amenities, which include shops, restaurants, banks, and also bus and train services. The home consists of a large detached building. The bedrooms of the care home are located on the ground floor and the first floor of the building. The home has two shared rooms, and seven single rooms. Two of the single rooms have en-suite facilities. The home has a passenger lift. The home has an enclosed maintained garden. There is parking for several cars at the front of the house. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of 64/66 College Hill care home took place during the day in October 2005. All the core standards were reviewed at the previous unannounced inspection in April 2005. This inspection afforded opportunity to look at the Requirements and Recommendations that had arisen at the previous inspection. The registered manager was on duty. There were no service user vacancies at the time of the inspection. A tour of the premises took place. A variety of policies and records were inspected. The Inspector had the opportunity to speak to the manager, staff on duty and residents and is grateful for their contribution to the inspection. 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. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 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 College Hill DS0000017528.V256485.R01.S.doc Version 5.0 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): 2 Every resident is given a statement of terms and conditions which is clear about what is provided as part of the fee. EVIDENCE: All the residents are from the local Harrow area except for two of the residents. Residents are provided with a statement of terms and conditions at the point of moving into the home. A contract is provided for the several residents purchasing their care privately. The statement is supplemented by the Harrow Social Services own statement for the Harrow residents. The inspector looked at these statements, all of which had been updated yearly and were signed and dated by the residents. The statement of terms and conditions covers the required range of areas to be covered such as the overall care and services to be covered by the fee. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 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): 8, 9 Arrangements are in place to ensure that residents’ health and personal care needs are assessed and met. Medication is safely stored and administered. EVIDENCE: Necessary developments in healthcare guidelines was highlighted at the previous inspection. Action by the registered manager has been prompt in regard to tackling issues that have arisen. In fact, immediately following the last inspection the registered manager contacted the District Nurse regarding pressure sores and a mattress was delivered the following day. The monitoring of weight loss and gain was systematic, along with the monitoring of oral hygiene in files looked at. The requirements from the last inspection have been tackled around medication. The medication policy was revised in June 2005 and now includes guidelines in regard to the administration of medication “when required”. Known allergies are recorded on all administration record sheets. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 9 Staff at the home are undertaking the Level 2 Certificate in ‘Managing and Safe Handling of Medication’, by ASET through Aylesbury College. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 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): 15 Meals provided are varied, nutritious and wholesome. EVIDENCE: The menu was displayed and the lunch being provided was wholesome and nutritious. Fresh vegetables were served with the lunch and fresh fruit was served as snack mid morning for all the residents. Positive comments were received from a number of residents spoken to; they also thought that a good food choice was offered; this choice is now recorded on the menu displayed. Staff were supportive to residents during the lunch and were aware of the dietary needs and preferences of residents. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 11 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): 17 Residents’ rights to participate in the political process are upheld. EVIDENCE: All residents are registered to vote by means of a postal vote. Residents are supported in the filling in of their postal vote forms by relatives. The registered manager oversees this process to ensure that it is properly carried out. Advocacy has been explored with Age Concern. One resident chose recently not to take up the use of an advocate. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 12 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, 21, 26 Some improvements to the décor have taken place, but further maintenance needs to be carried out. Residents are provided with comfortable, clean and safe surroundings. EVIDENCE: Some requirements from the previous inspection have been met. The steps leading to the storage shed have been repaired and old garden furniture disposed of. Some areas of the surface of the forecourt of the house that needed repair have been patched up, but overall remains uneven and needs totally resurfacing as it remains a slip hazard. The grab rail outside at the back has rotted at the end and needs to be replaced to support residents accessing the back garden. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 13 The bath enamel in one bath was chipped and needed repair. A sample of the residents’ bedrooms looked at were personalised. The registered manager has further continued to examine ways in which a bedroom could be reorganised to meet the preferences of two residents. The home is clean and free of offensive odours. The home is smoke free and a no smoking policy is implemented. No intermediate care is offered. The back garden is attractive and a gazebo which had proved very popular with several residents had just been taken down with the passing of summer. There was a rusting trolley in the garden used for transporting recycling and this should be considered being replaced by something more in keeping. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 14 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 Arrangements are in place to ensure that the skill mix and number of staff on duty enable the needs of residents to be met. EVIDENCE: The staff rota was inspected – liquid eraser had not been used on the staff records, as was the case on the previous inspection. The manager is a RMN and achieved NVQ Level 4 in June 2005. During the inspection, the manager was on duty with three other staff, one of whom was doing the cooking. A member of staff has been employed to undertake some domestic work. Staff spoken to were clear about their role, and were motivated to provide good care for the residents. Some positive comments were made by several residents about the qualities of staff members. The manager felt the ethos of the home was promoted through the continuity of the staff group and that no agency worker had ever been used. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 15 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): 33, 35, 38 There has been progress in developing financial procedures. One health and safety matter needs to be tackled to ensure the safety of residents is addressed. EVIDENCE: The financial policy in regard to the management of a residents financial needs has been reviewed and further developed to include policy and procedures in regards to residents who wish to keep financial documentation such as building society books on their person. Particular issues relating to a particular resident who had mislaid financial documentation and needed to inform a financial institution are in hand and being addressed. Food items stored in the fridge were covered and labelled with the date of opening. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 16 The cook, who was on leave at the time of the inspection, was due to undertake a certified food and hygiene course and had seen relevant videos on food hygiene. A carbon monoxide detector had been fitted as a result of a gas safety check; likewise the need to replace the metal relating to the boiler had been replaced on advice. Both boilers had been recently tested 5/9/05 & /6/9/05. Regular tests of the water systems must take place to check for legionella; the water temperature was monitored and recorded. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 17 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP19 Regulation 23(2)(b) 23(2) Requirement The nail on the front door at eye height needs to be removed Though some areas of the surface of the forecourt of the home have been repaired, there is an inconsistency of surface that needs to be rectified and a risk assessment recorded in regard to the unevenness. (Previous timescale of 01/09/05 only partially met) The enamel is chipped in the downstairs bathroom and needs filling Regular testing of the water needs to take place for legionella. Timescale for action 01/12/05 01/02/06 3 4 OP21 OP38 23(2)(b) 13(3) 01/12/05 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The medication policy should include guidelines in regard DS0000017528.V256485.R01.S.doc Version 5.0 Page 19 College Hill 2. 3. 4. 5 OP15 OP19 OP24 OP19 to the administration of medication when required. Any known allergies should be recorded on all the medication administration record sheets. It should be recorded on the menu that service users are offered choice. Old garden furniture should be disposed of. The registered manager should continue to examine ways in which a bedroom could be reorganised to meet the preferences of two service users. Consideration should be given to finding an alternative to the rusting shopping trolley used for recycling stored in the garden. College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 College Hill DS0000017528.V256485.R01.S.doc Version 5.0 Page 21 - 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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