Inspection on 28/06/06 for College Hill

This inspection was carried out on 28th June 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

College Hill 11/10/05

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 Judith Brindle Key Unannounced Inspection 28th June 2006 08:30 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 College Hill DS0000017528.V291490.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. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 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.V291490.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 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 is the registered manager and owner of the care 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 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. There is an enclosed maintained garden. There is parking for several cars at the front of the house. Information/documentation about the service and the range of fees is accessible from the care home to residents and others. Additional costs are recorded in resident’s statement of terms and conditions. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place during a day in June 2006. The inspector was pleased to speak to all the residents during the inspection. There were no vacancies at the time of the inspection. The purpose of the inspection was to spend time with the residents, assess key National Minimum Standards, and to follow up and assess as to whether requirements and recommendations from the previous inspection had been met. The inspection included a tour of the premises, and inspection of resident’s care plans, staff personnel records, medication storage and administration systems, and inspection of a variety of other records. The inspector also spent a significant part of the inspection talking with staff, and observing interaction between residents and staff. Observation was a significant tool used in the inspection process. Seven feedback/comment cards about the service provided by the care home were received from residents, six from relatives/visitors, and two from healthcare professionals were received by the Commission for Social Care Inspection prior to this inspection. The registered manager was present during the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. Requirements from the previous inspection were judged as having been met. The inspector thanks all the residents and staff, for their participation in the inspection process, and all those who kindly completed feedback/comment cards in regard to their views of the service provided by the care home. What the service does well: The care home has a welcoming atmosphere. Recorded feedback from service users, relatives/significant others confirmed this. The home has a motivated, and competent staff team. There is positive interaction between residents and staff. Staff have a very good understanding and knowledge of the residents varied needs. The registered manager is experienced and competent, and is pro active with her staff team in ensuring that a quality service is provided to residents. Recorded feed back from a relative described the care home as ‘excellent in all aspects’. Other feed back from relatives was also very positive about the service provided, staff were described as very ‘friendly and caring’. Two residents recorded in feedback/comment cards that they were very happy living in the care home. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 6 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.V291490.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (6 is not applicable) Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents have their needs assessed prior to moving into the care home. This assessment should be further developed. EVIDENCE: The care home has an admission procedure. The manager reported that the procedure generally includes a referral from the funding authority. This referral includes some assessment information. The registered manager then completes a level of dependency assessment of the prospective resident. She spoke of including the prospective resident (if they are able) and the relatives/significant others in this process of assessment. This information forms the basis of the individual care plans. There was recorded evidence of assessment of resident’s needs in the care plans inspected. These assessments should be further developed to include oral care, foot care, medication usage and personal safety and risk (See Standard 3). This was discussed with the registered manager. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 9 The manager confirmed that if the assessment indicates that the care home would be unable to meet the needs of the prospective resident this person is not admitted. The manager confirmed that residents have the opportunity to visit the care home prior to their admission. A resident spoke of visiting the home prior to their admission. Recorded questionnaires (located in the care plan documentation) in regard to resident’s preferences and needs, such as food preferences and spiritual needs were available for inspection. These were not always completed, and should be. The registered manager needs to apply for the registration of a service user with the Commission for Social Care Inspection due to the resident’s particular needs. This was discussed with the manager and the inspector arranged for the appropriate registration documentation to be supplied to the manager. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 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): Standard 7, 8,9,and 10 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s health social and personal care needs are set out in an individual care plan. Medication is stored and administered to residents safely. EVIDENCE: All the residents have care plans. Three care plans were inspected. These included the two care plans of residents recently admitted to the home. These care plans included assessment information, recorded goals and staff guidance to meet some residents’ identified/assessed needs. Care plans included information in regard to health, welfare and social needs. Staff were knowledgeable of the care plans. One staff member was in the process of reviewing a residents care plan and was observed to involve the resident in this process. Care plans are regularly reviewed. Recorded resident’s needs’, and staff action to meet those needs, require to be further developed to ensure that all identified needs are met, i.e. such as when behaviour from residents might challenge the service, and when residents are at times disorientated and might be of risk of wandering, and when a College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 11 resident’s nutritional assessment is recorded as high risk, and in regard to development of manual handling instructions. Daily residents progress records are documented. The care plans included risk assessment in regard to prevention of falls, and pressure sores, also manual handling assessments, but care plans need to be further developed to include more risk assessment such as individual bathing plans, and risk assessment in regard to the stairs. All residents should have a recorded inventory of their possessions. This was not evident in the inspected care plan documentation. Records confirmed that resident’s health needs are met. Appointments with the GP, dentist, community nurse, chiropodist, were documented. Resident’s weight is monitored. There was evidence that resident’s nutritional needs had been assessed. Records confirmed that residents have access to hearing and sight tests. A psychiatrist and a community nurse visited a resident during the inspection. The manager reported that there were no resident’s who had pressure sores, and that pressure relieving equipment when needed is accessible to residents. Recorded feedback from two healthcare professionals were positive about the service provided by the care home. The care home has a medication policy/procedure. Medication is stored securely, and was judged to have been administered safely during the inspection. The registered manager reported that staff have all recently received medication training from an external trainer. Medication administration records were fully recorded. The temperature of the medication cupboard is monitored. Resident’s privacy was observed to be respected during the inspection. Residents spoke of staff being understanding of their needs, and confirmed that they wear their own clothes. Residents have access to a telephone. Records are kept securely. The care home is registered in regards to Data Protection. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 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): Standard 12, 13, 14 and 15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to enable residents to participate in activities of their choice, and to maintain contact with family/significant others, as they wish. Meals are varied and wholesome. EVIDENCE: The care home has a recorded activity programme. Resident’s activity interests are recorded in their care plan documentation. Residents participated in an exercise session and a game of bagatelle during the inspection, which residents spoke of enjoying. Residents were observed to watch television, read newspapers and to listen to music during the inspection. Records and residents confirmed that residents participate in varied activities. These activities include doing jigsaws, reading, ball games, skittles, and music entertainment. A resident spoke of recently enjoying a party to celebrate her birthday. A resident spoke of her interest in attending a club located in the local community. It is recommended that systems be put in place to enable the resident to have the opportunity to regularly attend an Age Concern club. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 13 The day of the week is recorded and displayed on the wall, and there are a selection of books and puzzles accessible in the communal area of the home. Recorded feed back from a relative described the care home as making ‘every effort to stimulate and engage residents in conversation and appropriate activities.’ The care home has a visitor’s policy/procedure, which is generally ‘open’ visiting. Record confirmed that there are visitors to the care home, who visit their relatives/friends at varying times of the day. Residents kindly spoke of the visits that they received from family and friends. A resident spoke of regularly going out into the community with a relative. The menu was available for inspection. Recorded meals were judged to be varied and nutritious. Food eaten by residents is recorded. The care home employs a cook. The cook had an awareness of particular dietary needs of residents. Residents spoke of enjoying the lunch provided during the inspection, and of the meals in general. The lunch was unhurried and tables were laid attractively. When required, residents were given assistance with eating their meal from staff carried out in a sensitive manner. Residents were observed being offered choice in regard to their supper. Feedback from a relative informed the inspector that staff ‘always make sure that the food given to residents is what they like’. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 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 the following standard(s): Standard 16 and 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that complaints are dealt with promptly and effectively, and that residents are protected from abuse, but there needs to be review of recorded adult protection procedures. EVIDENCE: The care home has a complaints policy/procedure, which is displayed in the care home. There have been no recorded complaints since the last inspection. A resident spoke of speaking to a relative or a staff member if she had a concern or complaint. Recorded feed back from a relative informed the inspector that they were not aware of the complaints procedure. The registered person should examine ways to ensure that all visitors/significant others are aware of the complaints procedure. 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. This ‘in-house’ policy needs review to ensure that there is clarity that the Local Authority be informed prior to any investigation by the home. The home has a recorded whistle blowing policy. The registered manager confirmed that staff receive ‘in house’ abuse awareness training via video and complete a recorded questionnaire during the training. Information in regard to protection of vulnerable adults should be included in the staff induction programme. Staff who kindly spoke with the inspector had knowledge and College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 15 understanding of the reporting procedures in regard to protection of vulnerable adults. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 16 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): Standard 19 and 26 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The location and layout of the care home is suited for its stated purpose, and is generally well maintained, and very clean. Some maintenance issues need action by the registered person. EVIDENCE: The home is located close to Harrow Weald and Stanmore. A tour of the premises took place during the inspection. The home, including the enclosed garden is generally well maintained. Feedback from a relative described the environment as being ‘homely’. Fresh flowers and plants are located throughout the home. The registered manager spoke of ongoing and planned decoration of several areas of the home, and that two bedrooms had been redecorated. She informed the inspector that there have been maintenance problems with the home’s two boilers. One boiler had recently been replaced. The second boiler was not working at the time of the inspection. The registered manager College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 17 reported that an immersion heater was being used to ensure accessibility of hot water, but that the central heating in part of the house was not working due to the broken down boiler. She confirmed that this boiler was to be replaced within a few days following the inspection. This needs to be actioned by the registered person, and systems put in place to ensure that the temperature of the home is warm at all times. The light switch cord in a shower room was not very clean and should be replaced. The registered manager spoke of her plans to re surface the forecourt area of the home. Some uneven areas of this area have been levelled. The laundry facilities are located away from food storage and food preparation areas. The home has industrial type clothes washing and drying facilities. Hand washing facilities are accessible. The care home has an infection control policy/procedure. Staff were observed to have an awareness of appropriate infection control procedures. There is an accessible supply of disposable gloves and aprons in the care home. Recorded feedback from a relative described the care home as very clean. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 18 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): Standard 27,28,29 and 30 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that staffing numbers and skill mix meet the needs of the residents, and that residents are protected by the care homes’ recruitment and selection procedures. Staff receive appropriate training to ensure that they have the skills and competency to meet the needs of residents. EVIDENCE: The staff rota was available for inspection. Records confirmed that there are at least two care staff on duty at all times. At night there is one ‘wake night’ staff member and a ‘sleep in’ staff member of staff. The manager works varied hours, and records confirmed that she was present within the home most days. There is a part time cook and a staff member employed to complete domestic duties. The manager confirmed that staffing numbers are reviewed regularly to ensure that resident’s needs are met at all times. A student from a local college (completing a Btec care course) was completing a placement in the care home during the inspection. She spoke of her role in ‘shadowing’ staff and of her enjoyment of the placement particularly in regard to spending time with the residents, and receiving much support from the staff team. Recorded feedback from two relatives described the staff as being ‘always pleasant’, and that the home is ‘happy’ and ‘friendly’. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 19 The manager reported that three care staff have completed NVQ care courses, and that six staff are in the process of completing NVQ level 2 or 3 care courses, and that two staff will commence the course in the near future. The registered manager has worked hard to ensure that staff have the opportunity to completed NVQ care courses. A staff member described how the NVQ care course had helped her develop her skills, and to understand residents’ varied needs. The registered manager reported that she has spent time researching and accessing a variety of staff training courses. Staff training includes an induction programme. A staff member confirmed that she had completed induction training. Records confirmed that this training included First Aid training, health and safety training, fire training, and manual handling training. The manager informed the inspector of several free training courses that she had managed to access, which included staff attendance of seminars relevant to staff members role and responsibilities. These included abuse of older persons, mental health seminars, duty of care and prevention of pressure sores. There should be an accessible training plan for the year. Staff spoke of receiving regular supervision. The care home has a recruitment policy/procedure. Three staff personnel files were inspected. One file did not include evidence of two references and an application form of a recently employed member of staff. The registered manager supplied the Commission for Social Care Inspection with this documentation following the unannounced inspection. The manager confirmed that all staff receive a staff code of conduct, and an enhanced Criminal Record Bureau check. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 20 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): Standard 31, 33, 35,and 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The resident’s benefit from an experienced and competent management approach to the care home. There need to be development in recorded quality monitoring systems to ensure that the service provided by the care home is monitored and improved as necessary to meet the aims and objectives of the home. Resident’s financial interests are safeguarded, and the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager has managed the home for several years. She is a registered nurse, and completed the NVQ level 4 management course in June 2005. The manager reported that she had recently completed a certified ‘mentoring’ course. Records, and staff confirmed that the manager is fully involved in the responsibilities of the care home, and that she works several College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 21 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, and spoke positively of her. There are clear lines of accountability. Staff spoke of the manager being approachable and supportive. Recorded feedback from a relative of a resident described the care home as ‘well organised’. The care home has a quality assurance policy/procedure. The home has a business plan. There needs to be further development in regards to completing an annual development plan to ensure that there are appropriate systems in place for reviewing and improving the service provided by the care home. This was discussed with the registered manager. It was evident that review of care plans, policies, and other documentation took place. The manager and records confirmed that questionnaires have been supplied to residents and relatives/significant others about their views of the service. The value of giving residents the opportunity to participate in residents meetings was discussed with the registered manager. Residents should have the opportunity to participate in a regular residents meeting. Recorded feed back from a relative described the care home as ‘excellent in all aspects’. The care home has a financial policy/procedure in regard to resident’s monies. Relatives/significant others or the residents manage resident’s finances. Small amounts of monies for the purchase of toiletries and for hairdressing needs are managed by the home. Records are maintained and up to date. All residents should have an individual assessment in regard to the management of their monies. Pre inspection information and documentation informed the inspector that required checks and servicing of systems within the care home are carried out. These include electrical and gas system checks, and passenger lift servicing. Required fire checks and drills are carried out. The fire risk assessment had been recently reviewed. Health and safety risk assessments were available for inspection. The required health and safety poster was displayed. The home has a missing persons procedure. Records confirmed this procedure had been recently activated, following the actions of a resident. The registered manager needs to ensure that the Commission for Social Care Inspection is notified if the missing persons procedure is acted upon. The home has an accident policy and procedure. The registered person should record the action to be taken to prevent recurrence of an accident, and review the numbers and details of accidents on a regular basis. Legionella testing of the water takes place. The employer’s liability insurance certificate was displayed and up to date. College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 22 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation CSA Part 11, 13 Requirement The registered manager needs to apply for the registration of a service user with the Commission for Social Care Inspection due to the resident’s particular needs. Care plans need to be further developed to ensure that all identified needs are recorded in the care plan and that there is staff guidance to meet these needs. The ‘in house’ protection of vulnerable adults policy/procedure needs review to ensure that there is clarity that the Local Authority be informed prior to any investigation by the home. • The faulty boiler needs to be repaired. • and systems put in place to ensure that the temperature of the home is warm at all times. An annual development plan needs to be supplied to the Commission for Social Care Inspection. DS0000017528.V291490.R01.S.doc Timescale for action 01/08/06 2 OP7 12,13,14, 15 01/09/06 3 OP18 12,13(6) 01/09/06 4 OP19 23(2) 12/08/06 5 OP33 24 01/10/06 College Hill Version 5.2 Page 24 6 OP38 37 The registered manager needs to ensure that the Commission for Social Care Inspection is notified if the missing persons procedure is acted upon. 01/08/06 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 2 Refer to Standard OP3 OP7 Good Practice Recommendations Assessments should be further developed to include oral care, foot care, medication usage and personal safety and risk • Recorded questionnaires (located in the care plan documentation) in regard to resident’s preferences and needs, such as food preferences and spiritual needs should be fully recorded. • All residents should have a recorded inventory of their possessions. The registered person should examine ways to ensure that all visitors/significant others are aware of the complaints procedure. Information in regard to protection of vulnerable adults should be included in the staff induction programme. • The light switch cord in a shower room was not very clean and should be replaced. • The forecourt area of the care home should be resurfaced. There should be an accessible training plan for the year. Residents should have the opportunity to participate in a regular residents meeting. All residents should have individual financial assessments in regard to the management of their monies. The registered person should record the action to be taken to prevent recurrence of an accident, and review the numbers and details of accidents on a regular basis. 3 4 5 OP16 OP18 OP19 6 7 8 9 OP30 OP33 OP35 OP38 College Hill DS0000017528.V291490.R01.S.doc Version 5.2 Page 25 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.V291490.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!