Inspection on 10/08/05 for College House

This inspection was carried out on 10th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

College House 20/11/07

College House 25/10/06

College House 17/01/06

College House 03/11/04

College House 25/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 College House 26 Keyberry Road Newton Abbot Devon TQ12 1BX Lead Inspector Sam Sly Announced 10th August 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service College House Address 26 Keyberry Road, Newton Abbot, Devon, TQ12 1BX 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) 01626 351427 01626 351437 The Parkview Society Mr Wayne Steven Osbond Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2004 Brief Description of the Service: College House cares for adults aged 18 with a learning disability. Most residents currently are over 65 years old. The Owners are a local registered charity the Parkview Society that runs several care homes in the South Devon area. College House is a large detached bungalow in a residential area of Newton Abbot close to local amenities, and within a short walk of the bus route. The premises have a lounge with sitting area overlooking the well-maintained gardens which are accessible to residents, a kitchen and dining room and most of the bedrooms are on the ground floor. There is also two bathrooms one which is adapted, and additional toilets. The first floor is reached by stairs and has further bedrooms and the office and sleep-in rooms for staff. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was announced and took place on a weekday in August between 12pm and 4pm. The deputy manager Stuart Large was at College House throughout the visit. Evidence was collected by examining care records, staff files and health and safety records, talking to all but one of the residents, staff on duty and the deputy manager. A tour of all the communal areas, and those bedrooms that residents invited the Inspector into, was made. A meal was also shared with residents. Five residents also returned questionnaires to the Commission. What the service does well: What has improved since the last inspection? What they could do better: College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 6 There remained two outstanding requirements from the last Inspection; that care plans were reviewed at least six monthly and that all the required staff records were kept in the home at all times. It was of concern to find that a resident had been admitted without any care management assessment or plan, and without a detailed care plan developed in the home. Staff should receive sufficient adult protection training to be able to identify and correctly report abusive situations. The Owners must develop a system to demonstrate to residents and the Commission that quality is monitored, and improved at College House. 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 House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Prospective residents could not be confident that their needs and aspirations were assessed and understood. EVIDENCE: Most residents had lived at College House for many years and staff showed they knew these resident’s needs and met them appropriately. One resident was having their health needs reassessed by a professional in the next few days. There had been one new resident admitted, and although the deputy manager said he and some of the staff knew them previously, and had worked with them in the past, there was no Care Management assessment, risk assessment or care plan, despite the resident having spent time in a specialist unit before admission. This is not acceptable and could potentially put the resident or staff at risk. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Care plans do not clearly show residents how their care is to be provided, and by whom. Residents make many of the decisions about their lives, and are supported to be as independent as possible. EVIDENCE: Three resident’s care plans were examined, and one was looked at in detail with a resident. Discussion with this resident found that the plan did reflect their needs and goals and used a format and photos that they were able to understand. The deputy manager demonstrated that a ‘Person Centred’ way of planning for resident’s care had been started. This was a positive step, however the recorded plans required more detail on what support was to be provided and by whom, adapting to reflect the individual needs of the resident, and plans required dating and reviewing more regularly. The most recently admitted resident did not have a comprehensive care plan. Risk assessments were carried out, but resulting needs were not reflected in care plans. Risk assessments did not include resident’s money or medication. College House had a key worker system that worked well. Residents said they decided what to do and when. There were many examples throughout the visit of resident’s being supported to make decisions about their lives. Especially College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 10 about the activities, outings and holidays they took, the food that they ate and their surroundings. All residents had their own bank accounts, and were supported to have some control over their finances. One resident handled their own finances, and discussion took place about having goals for others to take more control of their money. There were accurate records for the money handled by the Manager and Deputy Manager. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 & 17 Residents lead active, stimulating, interesting lives within the home and the community. EVIDENCE: Residents were all taking part in activities, educational and employment opportunities suited to their ages and needs. Residents were involved in planning regular trips and holidays; recently going to the races, Cornwall, Butlins and Canterbury. With a coach trip and train journey planned for the near future. Residents also had activities in the home including art and craft, music, rug making, jigsaws, and cooking. Some residents went to the local Church, and use the community unsupported if able to. One resident was out at work on the day of Inspection. All residents said they were very happy with all the things they did. It was clear that residents made full use of the local community, and used local shops and amenities. Residents gave examples of being supported to maintain contact with people they cared about. One resident is supported to visit a College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 12 friend in Brixham, and the visit is returned at College House. This resident was pleased to be able to continue this contact. Staff numbers are increased to facilitate resident’s activities, and the routines of the day accommodate resident’s needs. All residents have locks to their bedroom doors and keys, however on the day of Inspection one resident did not know where they key was, bedroom doors did not appear to be locked, and one resident was entering bedrooms without being asked. A meal was shared with residents and enjoyed by all. Staff and residents sat together and the meal was relaxed, and unhurried. Staff helped those that required assistance, and residents were involved in laying the table and clearing away. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Residents receive support with medication, personal and health care in ways they prefer and require. EVIDENCE: The personal care needs of residents was detailed in their care plans, and discussion took place about recording more in their ‘person centred’ plan about what this support was and who would do it. Staff were seen to respect resident’s privacy and dignity during the Inspection. Residents were all dressed to reflect their ages, personalities and the time of year, and staff said they were involved in buying clothes, and getting their hair cut through the key worker system. Regular health checks were carried out, and relevant professionals involved to monitor and review changing health needs. A Learning Disability nurse was visiting one resident the following day, due to increased health needs. Discussion took place about finding the best GP service for residents, and the deputy manager was going to look into this further. None of the residents administered their own medication, and there was discussion about developing a risk assessment framework to promote selfmedication. The deputy manager said all staff administering medication had received training from the Pharmacy, it was recommended that certificates were available to demonstrate this. Medication receipt, recording, storage, administration and disposal were being carried out appropriately and only College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 14 minor recommendations were made. The Pharmacist visited regularly and was happy with the way medication was dealt with. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Residents can be confident that their views will be listened to and acted on, however, staff require more knowledge on how to protect residents for abuse. EVIDENCE: There was a clear complaints procedure, which residents were using. Residents concerns were being dealt with appropriately and records kept. None of the residents had any concerns on the day of Inspection and the Commission had not received any complaints about College House since the last Inspection. Although the manager and deputy manager had attended the Local Authority Protection of Vulnerable Adults training, none of the staff had, and a copy of the Alerter’s Guidance could not be found. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 29 Residents live in a comfortable, safe and homely environment. EVIDENCE: The home was light, bright, and maintained to a good standard. Bedrooms were decorated and furnished to reflect the needs and personalities of residents, and all the residents said they liked their bedrooms, and the house in general. Maintenance was done as and when needed, with a book kept listing shortterm requirements. Discussion took place about developing a maintenance plan that identified longer-term projects as well, which could be used to inform the home’s developing quality assurance system. The home is suitably adapted for the needs of one resident with a physical disability with a bedroom large enough for a wheelchair and hoist, an adapted bed, hoist and adapted bath. Residents have moved to ground floor bedrooms as their mobility needs have changed with old age. There were very few maintenance issues identified at the Inspection, however one bedroom had an offensive odour, which the deputy manager said they had College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 17 so far tried, but not succeeded in eliminating. Certain parts of the home got very hot during the summer months: the upstairs bedrooms, office and kitchen. A fan was available in the bedrooms and office, but the kitchen was extremely hot on the day of Inspection. Neither the Environmental Health nor the Fire Service had visited the home since the last Inspection. Regular fire checks were being carried out with the assistance of a resident. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 & 36 Residents benefit from services provided by a fit, competent, well-supported staff team, however records to demonstrate this were not available. EVIDENCE: Staff were enthusiastic, dedicated, approachable and interested in the residents and in their jobs. Staff said they received a good range of training that helped them meet resident’s needs. There were low sickness rates, and most of the staff team had worked at College House for many years and therefore knew the residents very well. Some staff had attended specialist learning disability training in total communication, induction into social care, epilepsy, autism and dementia care. Also the deputy manager said core health and all staff had done safety training, however the training plan for the home was unable to be successfully faxed through on the day of Inspection. Staffing levels were appropriate for the needs of residents, with at least 3 care staff, a cleaner and the deputy and sometimes, manager on duty during the day, and two sleeping staff at night. There was discussion about the changing needs of residents and the possible move to a staff member being awake at night in the future. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 19 Staff records were not all kept at the home, and this was made a requirement on the day of Inspection. Regular staff meetings took place and there were records of staff supervision sessions being held, and of some appraisals, and it was recommended that the training needs that are identified at supervision and appraisal are reflected in the Home’s training plan. Staff recruitment files seen had Criminal Record Bureau checks, references and suitable identification. The home did not have a staff interview format, and did not routinely record interviews. The acting manager said about 33 of care staff now had at least NVQ 2. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Resident’s health and welfare are protected through safe working practices. There is no quality assurance system to show residents and the Commission that College House is continually monitoring and improving the services it provides. EVIDENCE: The deputy manager provided a quality assurance format that the Owners were considering implementing, it was discussed with the Inspector and some improvements suggested. The format was not ready to be used yet, and required more emphasis on residents and stakeholders views. There were many monitoring systems in place that could, with some development feed into College House’s quality assurance system. The deputy manager said the Owners monitored and ensured that staff had up to date health and safety training including First Aid, manual handling, food hygiene and fire safety training. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 21 The Fire book and fire checks were up to date, and the deputy manager said a resident was involved in these checks, and that other residents had attended other training sessions. Accidents were being recorded appropriately. A wiring certificate had been issued, and electrical, hoist and gas checks were up to date. A monthly risk assessment was carried out of the environment, water temperatures were restricted and checks carried out to control Legionella. College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 3 x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 College House Score 3 4 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 23 Yes 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 2, & 9 Regulation 14 & 13 (4) (b) Requirement Comprehensive needs assessments and risk assessments, including money and medication, must be carried out before a resident is admitted. Care plans must reflect what support is to be provided and by whom. Care plans must be dated and reviewed six monthly or sooner if a residents needs change. (Previous timescale 30/12/04 - not met) There must be sufficient adult protection policies and procedures in the home, and staff must have all had appropriate training. The Home must have a quality assurance system that is underpinned by the views of residents and stakeholders. A report should be developed annually that is available for CSCI and other interested people that shows how the home has developed, and what still needs to be done to improve quality of care. All the required staff records must be kept in the home at all Timescale for action 19th September 2005 2. 6 15 19th September 2005 3. 23 13 (6) 19th November 2005 19th December 2005. 4. 39 24 5. 34 17 (2) Schedule 19th December Page 24 College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 4 (6) times (Previous timescale 31/01/05 - not met) 2005 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 7 20 Good Practice Recommendations The manager should make sure all residents have a key to their bedroom, and that discussion takes place about promoting privacy amongst residents. The manager should promote self-medication through a risk assessment framework. The homes medication policies would be better placed alongside the medication administration records. Handwritten changes to medication records should be checked and signed by two staff. Records to demonstrate that staff have received sufficient medication training should be kept in the home. The manager should have a maintenance and renewal plan, informed by regular environment checks that identifies any deficits with timescales for action. This plan can then inform the homes quality assurance system. Ways should be found to eliminate the odour in the identified bedroom. 50 of staff should have at least NVQ 2 by 31st December 2005. There should be a format for recording staff interviews and decision making about employment. Supervision and appraisals should highlight training that then informs the training needs assessment and plan for the whole staff team. 3. 24 4. 5. 6. 32 34 36 College House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon TQ12 7UP 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 House D54-D07 S3674 College House V231853 100805 Stage 4.doc Version 1.40 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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