Inspection on 13/04/05 for College Hill

This inspection was carried out on 13th April 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

College Hill 28/06/06

College Hill 11/10/05

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 Judith Brindle Unannounced 13 April 2005 10.15am 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service College Hill Address 64-66 College Hill Harrow Weald Middlesex HA3 7HE 020 8954 1235 020 8954 1668 Telephone number Fax number Email 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 Blasita Jeyarajah Mrs Blasita Jeyarajah CRH, PC 11 Category(ies) of OP (11) registration, with number of places College Hill Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7/9/04 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 Version 1.10 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 5.75 hours during a day in April 2005. 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. Care records, and staff personnel records were among a variety of records inspected. All the service users, the staff on duty, and a visitor kindly spoke to the inspector during the inspection. All the requirements following the previous inspection had been met. What the service does well: What has improved since the last inspection? What they could do better: There is a need to continue to improve some areas of the environment in regards to maintenance. Some care plan and policy/procedure records need further development. Please contact the provider for advice of actions taken in response to this College Hill Version 1.10 Page 6 inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. College Hill Version 1.10 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 Standards Statutory Requirements Identified During the Inspection College Hill Version 1.10 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 standard(s) 3 and 5 (6 is not applicable). All service users have their needs assessed prior to moving into the care home and during the trial period to ensure that the service can meet prospective service users needs. Service users and their relatives/significant others have the opportunity to visit the home prior to their admission to assess the suitability of the home and the quality of the service. EVIDENCE: The home has an admission procedure. There is comprehensive assessment of individual service users’ needs prior to their admission to the home and during the ‘settling in’ period. Service users recently admitted to the home had recorded full assessment of their needs. Documentation confirmed that service users are involved in this assessment process. Service user questionnaires completed during the assessment process included information on service users preferences and needs. Records confirmed that staff action is taken to meet these needs. College Hill Version 1.10 Page 9 Assessment documentation and information is comprehensive. Physical, psychological, spiritual needs are assessed. Assessment also includes risk assessment. Staff who kindly spoke with the inspector had knowledge and understanding of service users needs. Four service users who spoke to the inspector confirmed that their needs were being met. Information provided by a service user concerning their personal needs was recorded in the care plan documentation. Records and a service user confirmed that a service user had visited the home with their relative prior to admission. Another service user spoke of her relative visiting the care home, but not her visiting prior to admission due to being admitted from hospital. There is a trial period before a service user and/or their representative makes a decision to stay. College Hill Version 1.10 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 standard(s) 7,8,9 and 10 Arrangements are in place to ensure that service users health and personal care needs are met, and that their privacy and dignity is respected. There needs to be some development in recorded staff guidance to meet some identified care needs. Medication is stored and administered safely. EVIDENCE: All service users have an individual plan of care, which is generated from a comprehensive assessment. The four care plans inspected included documentation and information, which (due to the care plan format) was easily accessible for reference by staff. Each service user has a plan of care for daily living and recorded longer-term goals. Assessment includes risk assessment of falls, and nutritional assessment, and recorded guidance to minimise assessed risk. Records confirmed service user involvement in the review of their care plan. Guidance was included in regard to the staff action required to meet some identified assessed service users needs. There needs to be development in some healthcare guidelines, such as service user oral care needs. Two service users particular individual oral care needs were discussed with the registered manager. College Hill Version 1.10 Page 11 Records, service users, and staff confirmed that service users access dental facilities, chiropody services and optician services. All the service users are registered with a GP. Service users’ weight is monitored. A service users’ weight needs to be monitored more regularly due to significant recorded weight loss. Records and service users confirmed that service users attended hospital appointments. All the care plans inspected confirmed that service users receive pressure area risk assessment, with recorded guidance to meet these assessed needs. The registered person needs to seek advice from the community nursing service in regard to further assessment of an individual service users’ pressure area needs, and then access pressure relieving aids (particularly for nighttimes) if assessed as needed for a service user. This was discussed with the registered manager. Daily records are maintained of service users progress and changing needs. Medication is stored in a locked facility, and was administered during the inspection. A staff member who spoke with the inspector had knowledge and understanding of appropriate medication procedures, and of the importance of reporting issues to do with the safety aspects of medication. Records are kept of medication received and disposed of. There are no service users who selfadminister medication. The medication policy should include guidelines in regard to the administration of medication ‘when required’. Any known allergies should be recorded on all the medication administration record sheets. Staff signatures and their initials are recorded. Staff were observed to have and understanding and respect for service users privacy and dignity. Service users spoke of staff being respectful of their personal privacy. A service user received a visitor in her own room during the inspection. College Hill Version 1.10 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 standard(s) 12,13,14 and 15 There has been progress in the provision of varied leisure and social activities for service users since the last inspection. Service users participate in a variety of daily activities. Service users are supported in the management of their finances. Service users are supported in maintaining contact with relatives/significant others. Meals provided are varied and wholesome. EVIDENCE: The care home has a recorded weekly activity programme. The activity observed during the inspection was as recorded on the weekly activity programme. Service users were observed participating in an exercise session. Two service users informed the inspector that they enjoyed these sessions. Service users were offered choice in regard to their participation in activities during the unannounced inspection. Activities participated in by each individual service user, is recorded. These activities included manicure sessions, foot spa sessions, and listening to music and watching videos. Service users spoke of leisure activities that they enjoyed. These included knitting, television, music cards and reading. Service users’ leisure preferences are recorded in their care plans. The television was turned off at lunchtime and a choice of music provided. College Hill Version 1.10 Page 13 The care home has a visitors’ policy. A visitor confirmed that they could visit at anytime and felt welcomed. Service users spoke of receiving visitors. The visitors’ book informed the inspector that there were frequent visitors to the care home. Service users are supported by relatives/significant others in the management of their finances. Some service users manage their own finances. Records of two service users monies were inspected and the balances were correct. The manager reported that she was supporting a service user to claim entitled personal allowances. The menu was displayed, and the recorded lunch was the meal provided during the inspection. Two weeks menu was inspected. Meals recorded were varied and wholesome. Staff were aware of the particular dietary needs of a service user, and of the dietary preferences of others. Service users spoke of enjoying the meals provided and of having choice. It should be recorded on the menu that service users are offered choice. A choice of fresh fruit was offered to service users during the unannounced inspection. Records confirmed that snacks were provided at anytime that service users requested, including during the night. Food eaten by service users is recorded. College Hill Version 1.10 Page 14 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 standard(s) 16 and 18 Arrangements are in place for handling complaints objectively. Service users are aware of how to complain, and were confident that concerns would be listened too. Systems are in place in regard to the responding to any suspicion or allegation of abuse. Development in service users financial procedures is needed. EVIDENCE: The home has a complaints policy. This is displayed within the home. There have been no recorded complaints since the last inspection. Service users spoke of having confidence to communicate ‘concerns’ to staff if they needed too. The care home has the Local Authority protection of vulnerable adults policy and procedures. There are also accessible ‘in house’ procedures in regard to responding to suspicion or allegation of abuse. The home has a recorded whistle blowing policy. College Hill Version 1.10 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 standard(s) 19,24 and 26 Some improvements to the décor have been carried out. Other improvements are planned. There needs to be some maintenance carried out. Service users bedrooms are personalised. The service users are provided with clean comfortable and safe surroundings. EVIDENCE: The environment has some homely features, which include houseplants, a fish tank and displayed pictures. There has been some redecoration of some areas of the premises since the last inspection. These include some redecoration of communal areas, and some areas of the kitchen. The steps leading up to the storage shed need repair. There needs to be a risk assessment in regard to the possible slip hazard from the paving stones, (particularly when wet) which lead from the garden steps to the storage facility. Old garden furniture should be disposed of. There are some areas of the surface of the forecourt of the house that need repair. There needs to be a risk assessment recorded in regard to the areas of uneven forecourt surface. College Hill Version 1.10 Page 16 The registered manager reported that there were plans for further maintenance to be carried out. A sample of service user bedrooms was inspected. These bedrooms were individually personalised. A service user spoke of being satisfied with their room. The registered manager should continue to examine ways in which a bedroom could be reorganised to meet the preferences of two service users. This was discussed with the manager. The home is clean and free from offensive odours. Laundering facilities are located away from food storage and food preparation areas. Protective clothing (such as disposable gloves) was observed to be accessible and used by staff. Certificates confirmed that staff had received infection control training. College Hill Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Arrangements are in place to ensure that the number and skill mix of staff on duty enable needs of service users to be met. The recruitment procedures include required safeguards to offer protection to people living within the home. The registered manager has commitment to ensure that staff receive varied on going training. Staff are appropriately trained to enable them to be competent to meet service users assessed needs. EVIDENCE: Five weeks staff rota was inspected. Liquid eraser must not be used on the staff rota records. Records confirmed that there are at least two care staff on duty at all times. The manager works varied hours, and records confirmed that she was present within the home most days. During the inspection the manager was on duty with two care staff and a cook. The manager reported that staff recruitment is in progress in regard to recruiting a domestic member of staff, and night duty staff member. The staff files of two staff members were randomly selected. This documentation indicated that the home has undertaken the necessary recruitment checks to ensure protection of service users. Service users spoke positively of the care and support that they received from staff. Staff responded promptly to requests from service users during the unannounced inspection. Several of the staff team have worked in the home for several years, and staff that spoke to the inspector had understanding of College Hill Version 1.10 Page 18 service users individual needs. Staff were observed to interact with service users in a sensitive manner. There is a call bell system. This was tested and in working order. Records confirmed that staff complete an induction programme, and receive a variety of appropriate training to develop their knowledge, competency, and skills. This training includes health and safety training, food and hygiene training, fire training, medication, and moving and handling. Staff confirmed that NVQ in care training was on going. The registered manager reported that staff have the opportunity to commence a NVQ level 2 course following six months of employment. A staff member reported that she had almost completed an NVQ level 3 care course. The registered manager informed the inspector that the Registered Managers Award final course work that she had completed was in the process of being verified. This is positive for the service. Staff who spoke to the inspector were very motivated in providing quality care. College Hill Version 1.10 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33, 35 and 38 There is leadership, direction and guidance for staff to ensure that service users receive consistent quality care. Development in regard to service users financial procedures needs further development. The health and safety of service users is an issue identified by the service and promoted. EVIDENCE: The registered manager has managed the home for several years. Records, and staff confirmed that the manager is fully involved in the responsibilities of the care home, and that she works several varied shifts. Staff confirmed that the registered manager, when off duty, was accessible for guidance and direction when needed. Service users who kindly spoke to the inspector were aware of whom the manager was. It was observed that service users knew the registered manager well. Service users and a visitor made positive comments about the staff team. College Hill Version 1.10 Page 20 The financial policy in regard to management of service users financial needs, needs to be reviewed and further developed to include policy, and procedures in regard to service users who wish to keep financial documentation such as building society books on their person. A service user needs to be supported and encouraged to inform the relevant financial institution in regard to mislaid financial documentation. Appropriate statutory authorities need to be informed if there is suspicion of theft. Food items stored in the fridge were covered. These items need to be labelled with the date when opened. The recently employed cook needs to complete training in a certified food and hygiene course. Required fire safety checks are carried out. Records and staff confirmed that staff receive fire instruction monthly, and that fire drills took place regularly. The last recorded fire drill, which included participation from service users, and staff was 12/4/05. Radiators are covered. A required health and safety poster was displayed. Fridge/freezer temperatures are recorded. Portable appliance checks were completed February 2005. College Hill Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 2 x x 2 College Hill Version 1.10 Page 22 NO 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. Standard 8 Regulation 12(1)13, 14 12(1)13, 14 12(1)13, 14 Requirement There needs to be some development in some healthcare guidelines, such as oral care needs. A service users’ weight needs to be monitored more regularly due to significant recorded weight loss. The registered person needs to seek advice from the community nursing service in regard to further assessment of an individual service users’ pressure area needs, and then access pressure relieving aids (particularly for nightime) if needed for a service user. The steps leading up to the storage shed need repair. There needs to be a risk assessment in regard to the possible slip hazard of the paving stones (particularly when wet) leading from the garden steps to the storage facility. There are some areas of the surface of the forecourt of the house that need repair. There needs to be a risk assessment recorded in regard to these areas of uneven Version 1.10 Timescale for action 1/7/05 2. 8 1/7/05 3. 8 1/7/05 4. 19 23(2) 1/8/05 5. 19 23(2) 1/9/05 College Hill Page 23 surface. 6. 7. 27 35 17 13(4)(6) Liquid eraser must not be used on the staff rota records. The financial policy in regard to management of service users financial needs, needs to be reviewed and further developed to include policy, and procedures in regard to service users who wish to keep financial documentation such as bank books on their person. A service user needs to be supported and encouraged to inform the relevant financial institution in regard to mislaid financial documentation. Appropriate statutory authorities need to be informed if there is suspicion of theft. Food items need to be labelled with the date when opened. The cook needs to complete training in a certified food and hygiene course. 1/6/05 1/8/05 8. 35 13(4)(6) 1/6/05 9. 10. 38 38 13(4) 13(4)18 (1) 1/6/05 1/8/05 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 9 Good Practice Recommendations The medication policy should include guidelines in regard 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 oferred 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. 2. 3. 4. 5. 6. 15 19 24 College Hill Version 1.10 Page 24 College Hill Version 1.10 Page 25 Commission for Social Care Inspection 4th 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 Version 1.10 Page 26 - 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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