Inspection on 13/07/07 for College House

This inspection was carried out on 13th July 2007.

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 House 01/10/09

College House 08/07/08

College House 04/01/07

College House 07/10/05

College House 13/12/04

College House 27/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE College House College House 20 College Road Fishponds Bristol BS16 2HN Lead Inspector Sandra Jones Unannounced Inspection 09:30 13th July 2007 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 House DS0000040202.V336522.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 House DS0000040202.V336522.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service College House Address College House 20 College Road Fishponds Bristol BS16 2HN 0117 9651144 NONE benoograh@hotmail.com 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) Highcleeve Limited Mrs Prema Sheishrybye Oograh Mr Benoy Kumar Oograh Care Home 21 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (6), Old age, of places not falling within any other category (21) College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 21 persons aged 65 years and over requiring personal care only. The home may at any one time accommodate up to 6 people with mental disorder (not dementia) aged 65 years and over Complete a fire risk assessment and amend the current fire policy to take account of the increase in bed numbers and also the sit tight policy Assess the dependency levels of service users and, if necessary, increase staffing levels accordingly. 4th January 2007 Date of last inspection Brief Description of the Service: College House is registered to provide accommodation and personal care for older people. It is located in the Fishponds area of Bristol close to the local amenities and shops, Post Office and banks are all in easy walking distance for those who are able to mobilise independently. Each bedroom has been furnished to service users individual choice and 10 of these rooms have en-suite facilities. The dining room and lounge area are on the ground floor and are easily accessible to all service users. There is a chair lift to aid those less mobile service users to move around the home along with other aids, such as a hoist and rails etc. College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced in July 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. Eleven completed “Have your say” surveys were received at the Commission from people who use the service. Feedback from relatives and Health and Social Care Professionals was sought through comment cards. Five relatives responded through “Have your say” surveys, a questionnaire from the district nurse and three GP’s that visit the home completed comment cards. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. Four people were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered either by face- to- face discussions or by surveys. What the service does well: Relatives that responded through surveys stated that the home provides a safe and caring environment. “Sensitive and caring staff” was the direct comment made by a GP that visits the home. Comments made by the individuals at the home indicate that members of staff are friendly yet respectful and they know who to approach with complaints. Good standards continue to be maintained at College House and individuals benefit from living in a homely and comfortable environment. The home is well managed and staff receive the appropriate supervision and training. College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 6 The recruitment procedure is robust and protects vulnerable adults. 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. The summary of this inspection report can be made available in other formats on request. College House DS0000040202.V336522.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 House DS0000040202.V336522.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Sufficient information is provided to individuals to make choices about living at the home. The admission process must be more detailed to reassure individuals that the home will have the skills and resources to meet their assessed needs. EVIDENCE: The prepared Statement of Purpose describes the admission process followed at the home. It states that assessments of need will be conducted and probationary periods will be offered to ensure compatibility of both parties. It also purports to offer respite care. For people placed by the Local Authority, social workers assessments are provided and for people that self fund their College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 9 placements the service provider conducts an initial assessment. Introductory visits to the home are encouraged so the potential person can experience what living at the home is like. The Statement of Purpose must be reviewed to make the admission criteria clear to individuals wishing to live at the home, their representatives and placing agencies. The service provider stated that each person will be provided with a copy of the Terms and Conditions of residency and copies are kept on file. Five admissions occurred since the last inspection and the case files of two people were examined. The Local Authority placed both individuals and social workers assessments were provided to the home before the admission. Nine “Have your Say” surveys were received from people living at the home state that they received enough information about the home before moving into the home. Two people stated that they had not received any information about the home. Direct statements such as “I came in for the day and had fish and chips” and another said, “ I came for a day visit, before I chose to move in.” A recently admitted person was consulted about living at the home and confirmed that the home provided sufficient information to make decisions about moving into the home. College House DS0000040202.V336522.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning systems is clearer for staff to follow and people living at the home receive individualised care. It would benefit from having more detailed information so that individuals at the home can benefit from receiving a consistent service. People at the home can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: Significant steps have been taken to improve the care planning system. Areas of need are clearly described, with the timescales and the person delegated to undertake the task. A Summary of Risks is part of the care plan and is based on the risk of falls, nutrition, mental health and medication. The triggers of aggression and actions to be taken are briefly described in the summary of College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 11 risks. The actions to be taken by the staff must more detailed in order to guide the staff to meet the need. The person signs care plans and the service provider stated that copies of care plans are also handed to the person. Four people at the home were consulted about the care planning process. One person could remembers having a care plan meeting and signing the care plan others were not able to recall having a care plan. Eight “Have your say” surveys from individuals state that they receive the care and support they need, two people said it was sometimes and one said it was usual. “Have your say” surveys were also sent to relatives and five responses were received. Two relatives stated that home always provides the support needed by the individual at the home and two stated it was usual. One relative made direct comments that relate to the care planning process and, it was stated “ Always involved in yearly reviews.” Two staff were asked about the care planning process and stated that there is an expectation that they read the care plan and compile weekly evaluation sheets. The service providers stated that there is a keyworker system in operation. There is an expectation that keyworkers complete weekly evaluation reports about the progress of the care plan, health care reports and reviews form part of the weekly evaluation reports compiled by the keyworkers. Members of staff on duty confirmed their responsibility to compile evaluation sheets. The four individuals consulted were able to name their keyworker and describe the tasks undertaken by their keyworkers. It was stated that purchasing toiletries and providing personal were part of the role of the keyworker. Where there is a history of falls, risk assessments are completed and determine the level of risks. The service provider stated where the assessment identifies a medium or high risk; the need is then included within the care plan. Individuals personal health care need is clearly described within the care plans and running reports are linked to the care plans along with staff’s observation of the person. It is evident from the running reports that individuals have input from Health Care professionals, GP’s, district nurses and chiropodists and their advice is followed. Ten surveys from people living at the home stated that they always receive the medical support they need and said it was usual. One person said, “When I need them, they come.” Two people giving feedback about their health care stated that GP visits take place in their bedroom and where needed the staff are present. Another person said that they are able to visit the GP without staff support. Three “Have your say” surveys from relatives indicate that the home keeps them informed about important issues affecting the individual living at the home and two stated it was usual. Members of staff said that unless specified the care staff are present when the GP visits the home. The staff were consulted about the arrangements in place that ensure health care advice is followed. It was stated that to ensure advice is followed, outcome of visits are recorded in the evaluation sheet, care plans and handover sheets. “Have your say” survey College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 12 was received from a district nurse and confirmed that the home seeks advice and act upon it to manage and improve the individuals health care needs. The district nurse also stated that the health care needs are always met by the care service. The district nurse made the following statement “ As regards the patients registered to our GP practice, I have no doubt that advice is sought appropriately from health care service.” Three comment cards were received from GP’s that visit the home and stated that specialist advice is incorporated into the care plan. Medication is administered through a monitored dosage system and the records of administration indicate that staff sign the records immediately after administering medications. The service provider stated that homely remedies are not administered from a stock supply when required. A record of medications no longer required at the home is maintained which is signed by the pharmacist to indicate receipt of the medication for disposal. Information leaflets are available for some of the medications administered. The service provider must ensure that information leaflets are available for all medications administered at the home. There is a Privacy/Dignity/Confidentiality policy, which describes the approach that will be followed at the home. The policy is clear about the commitment towards respecting the individuals. Members of staff were consulted about the way practices at the home ensure individuals rights are respected. It was stated that conducting personal care in private, ensuring that people can undertake visits in private and knocking on doors were tasks that ensured individuals rights were respected. Four individuals giving feedback confirmed that their dignity and privacy is maintained at all times one person said “Its all private.” Another person said that their mail is handed to them unopened and, they have a single lockable bedroom. The district nurse that visits the home stated through the survey “ In my opinion respect is a priority.” The contract of residency informs individuals that personal possessions can be taken into the home. There is a pay phone and cordless phone available to individuals to make calls. College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good support systems in place for individuals to lead active and interesting lifestyles EVIDENCE: Care plans incorporate the individuals social care and communication needs. Activities generally take place in the afternoons between 3:00 and 4:00 Monday - Friday and the rota of activities indicated that exercising, music, current affairs and bingo are organised. Members of staff record within the daily report the activity undertaken and the most common activities are bingo and singing. Members of staff described the arrangements in place for inhouse activities. It was stated that the individuals at the home are asked to join the activities and the size of the group is dependant on the activity. The member of staff further stated that the people living at the home are sociable and want to interact with each other. Individuals at the home were consulted about the way they spent their day at the home. One said that watching television was the way they preferred to spend their day, and they did not College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 14 want to do any other activity. Two said that it was their preference to sit in the quiet lounge or in the garden during warm periods and not participate in activities. Another said that they participated in the activities organised by the staff at the home. Eight “Have your say” surveys from individuals at the home state that activities are always organised. Direct comments from these individuals include “They have exercises, ball games and bingo” and another stated “Yes but I don’t take part in them.” The home’s visiting times are on display in the foyer of the building and are included within the Statement of Purpose. Four people giving feedback confirmed that the staff welcome their friends and family whenever they visit the home. In terms of privacy individual stated that bedrooms could be used for additional privacy. Four “ Have your say” surveys from relatives indicate that the home always supports individuals to maintain contact with family and friends. One relative stated that it was usual for the home to support individuals to keep in contact with relatives, it was further stated “Perhaps the care home could make it more comfortable feeling to ask to use the phone.” The service provider said that there is an expectation that the people at the home make their own financial arrangements. Individuals at the home have family involved in their care and for this reason advocates are not used at the home. The service provider was consulted about the arrangements for meals at the home. It was stated that members of staff have a combined role of cooking and cleaning. There is a three-week rolling menu and before each meal time staff will ask individuals to choose a meal from the choices given. Members of staff on duty were asked about the meals served at the home and one stated that three staff are rostered and one person will undertake catering tasks. This member of staff further stated that individuals are asked on a daily basis to select their preferred meal and mostly they select the same meals. There is a good range of fresh, frozen and tined foods at the home and reflect the menus in place. However, the menus are repetitive. Individuals consulted about the meals served stated that the meals were good and they always had enough to eat. One person said “ I have put two and half stone since coming to the home.” Eleven “Have your say” surveys were received from individuals at the home. Nine people indicated that they always like the meals prepared at the home, one person stated that they sometimes liked the meals and another said it was usual. One person made a direct comment about the meals served at the home. It was stated, “Very much so. I think they are wonderful, I am a fussy eater and I get plenty of choice.” College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals at the home can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The Complaint procedure is on display in the foyer of the building and included within the home’s Statement of Purpose. The service provider said that copies of the complaints procedure are provided to the person during their admission to the home. The current procedure is not available in large print or in a simple format so that it can be understood by the people it’s intended. There were no recorded complaints since the last inspection. Feedback was sought from four individuals at the home about making complaints. One person said that any member of staff could be approached with complaints and three said that they would approach the service provider and deputy. One person said, “I would go to the service provider with complaints, he is the type of person that would listen.” Eleven “Have your say” surveys were received from individuals at the home and nine stated that they know who to speak to if they are not happy and two said they usually knew. The eleven surveys from individuals indicate that they know how to College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 16 make a complaint. Six “Have your say” surveys were also received from relatives and five stated that they know how to make a complaint and one person said they did not know how to make a complaint. Two relatives also stated that they home has always responded appropriately to their complaints, two said it was not applicable and one said it was usual for the home to respond appropriately. Members of staff have attended Safeguarding Adults training and the service provider is a link trainer for Bristol City Council. Members of staff on duty were consulted about their responsibilities towards safeguarding adults from abuse. Members of staff were able to describe the factors of abuse and are clear about the actions to be taken to safeguard the people at the home. The service provider said there were no outstanding safeguarding adults referrals. College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained so individuals benefit from living in a comfortable and clean environment EVIDENCE: College House is a large detached property close to the Fishponds Road, local amenities, shops and bus routes. It is arranged over two floors, with bedrooms on both floors and shared space on the ground floor. The chairlift to the first floor assists less mobile residents to move around the home. Bedrooms are lockable and with the exception of one, bedrooms are single. The service provider stated that individuals that specify during admission that College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 18 they wish to share a bedroom use the double room. For example, couples. It is evident from the tour of the premises that individuals are encouraged to have personal belongings in their bedrooms to make them homely. There are two large lounges at the front of the property, with a smaller quiet lounge to the rear. The dining room has sufficient seating for the individuals living at the home to eat their meal together. The property is well maintained both internally and externally. The service provider stated that since the last inspection, upstairs bedrooms were redecorated. Laundry facilities are sited away from the kitchen. The floor covering is waterproof and wall finishes are readily cleanable. Cleaning substances are kept in a locked cupboard in the laundry room. Two domestic washing machines are used to launder residents clothing. The washing machines are not equipped with a specified programme for foul linen. There are sluicing facilities available at the home for soiled linen. The eleven “Have your say” surveys from individuals at the home state that the home is always fresh and clean. Direct comments from individuals include “ First class” and “Yes very nice and clean. It’s wonderful how they do your bits and pieces for you and they offer help.” College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A competent, qualified and skilled staff team who are well supervised supports individuals at the home. EVIDENCE: There is a four-week rolling staff rota and generally three staff are rostered between 8:00 am and 6:00 pm, from then onwards the staffing levels fall to two staff. At night there are two staff rostered, one awake and one asleep. Ancillary staff are also employed and work during the week to maintain the home clean. A manager is on duty throughout the day including weekends. Eight “Have your say” surveys from individuals indicate that staff are always available when they are needed. Three people stated that it was usual for staff to be available when needed and one said it was sometimes. The service provider was consulted about vocational qualifications. The service provider stated that four staff have completed NVQ level 2 and another four are registered onto the course. Two staff were consulted about access to College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 20 training. One person has completed the NVQ levle2 course and the other was undertaking the Skills for Common Standards Induction. The personnel records of the five most recently employed staff were examined during the inspection visit. The records contain completed application forms, two written references, Criminal Records Bureau (CRB) disclosures and Terms and Conditions. One member of staff on duty was recently employed through an overseas agency and confirmed that an interview was conducted and evidence that establishes their suitability to work with vulnerable adults was sought. There is a training programme and all staff must undertake Food Hygiene, First Aid, Moving and Handling, Infection Control and Safeguarding Adults training. For staff to have specific knowledge of the needs of the people accommodated, mental health training is provided. The service provider stated that mental health and medication training would form part of the home’s training programme. Regarding new staff, the service provider said that staff employed since January 2007 must undertake the Skill for Care Common Induction Standards at the home. A member of staff on duty was consulted about the training programme and stated that since the last inspection mental health awareness training, Food Hygiene and Common Standards Induction programme was undertaken. The “have your say” survey from the district nurse states that the staff usually have the right experience to support the people at the home. Further comments made indicate that staff will seek support from outside agencies. Three GP’s comments cards indicate that staff have an understanding of the care needs of the people at the home. Four surveys were received from relatives and one person stated that the staff always have the skills and experience to look after the people at the home. Two people stated it was usual for the staff to have the skills and experience and one said it was sometimes. “Confident with the core team staff but there does seem to be a high turnover of staff so unsure of all skills” was a direct comment made by a relative. Four individuals were consulted about the staff at the home and their comments indicate that the staff treat individuals well. Comments made by individuals at the home include “ I am happy and well cared for” and “ Staff are wonderful you couldn’t have better.” College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people living at the home can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring. EVIDENCE: The arrangements for the day-to-day management of the home were assessed. The service provider is the person in charge of the day-to-day management of the home. The service provider described the training that ensure that individuals living at the home benefit from strong leadership. As a qualified nurse the service provider undertakes 35 hours of clinical training to maintain their pin number. NVQ level 4 and the Certificate in Management Studies were also undertaken to successfully operate the care home. It was College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 22 then stated that an approachable and fair style of management is used. Leading by example, flexibility and not too disciplined also ensure that standards of care are maintained. In terms of the systems that offer consistency of care, the service provider stated that individual supervision and staff meetings were used. It was further stated that all staff have quarterly supervision, which is part of staff’s personal development and six monthly staff meetings. There is an expectation that all staff attend staff meetings. The members of staff giving feedback confirmed that the service provider is approachable, will listed to their concerns and while they are not perfect they are not bad either. One member of staff said that the service provider and deputy had been good to them in the past. Staff’s comments indicated that staff meetings and individual supervision take place. The Statement of Purpose was discussed with the service provider. It was stated that the intention is to continue with the current age range of over 65 years because the staff and premises are equipped to meet the needs of older people. The intention is to continue to offer accommodation to people over 65 years. The service provider was consulted about the Quality Assurance system in place at the home. It was stated that relative and service users questionnaires are used to seek their feedback about the services offered at the home. The information received through questionnaires is then analysed and where gaps are identified action is taken to raise the standards. Cash is currently held is safekeeping on behalf of the people accommodated at the home. The sample check of cash in safekeeping was conducted and records are up to date, with receipts to evidence the purchases made on behalf of the person. Fees to be paid by the individual are included within the terms and conditions of residency. The service provider has employed an outside company to undertake Health and Safety and fire risk assessments to satisfy the Regulatory Reform (Fire Safety) Order 2005. Other checks undertaken to maintain a safe environment for the people that use the service include annual checks of the heating system and portable equipment. A specific accident book was purchased to better report on accidents and incidents. There are eleven recorded accidents and the service provider said that the records are periodically analysed and where appropriate care plans are amended. College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 23 College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 24 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 3 3 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 3 College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 12(1)(a) Requirement To ensure that service users who are offered analgesia when they complain of pain but refuse it have that recorded on their MAR sheet. To review risk assessments and care plans relating to falls after any incidents/accidents. To ensure that any significant changes to a service users condition are recorded. Timescale for action 14/09/07 2. OP7 13(4) & 15 14/09/07 3. OP7 15 14/09/07 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 OP8 Good Practice Recommendations That staff are clear about their Accident policy so that they DS0000040202.V336522.R01.S.doc Version 5.2 Page 26 College House follow that consistently. College House DS0000040202.V336522.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000040202.V336522.R01.S.doc Version 5.2 Page 28 - 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!