Inspection on 17/01/06 for College House

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

College House 20/11/07

College House 25/10/06

College House 10/08/05

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 Unannounced Inspection 17th January 2006 13.30p College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 1 College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 2 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 DS0000003674.V279470.R01.S.doc Version 5.1 Page 3 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 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 DS0000003674.V279470.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Name of service College House Address 26 Keyberry Road Newton Abbot Devon TQ12 1BX 01626 351427 01626 351437 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) 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 DS0000003674.V279470.R01.S.doc Version 5.1 Page 5 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 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 wellmaintained 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 DS0000003674.V279470.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and took place on an afternoon in January. 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 five residents and the staff on duty including the deputy manager. All the communal areas of the house were seen, and the bedrooms of those residents that invited the Inspector into. What the service does well: What has improved since the last inspection? What they could do better: It was concerning to find that of the five requirements made at the last Inspection in August 2005 only one had been met. The Commission will be carrying out a follow up visit in April 2006 to ensure full compliance. All toxic chemicals must be locked away when not in use and all fire doors must be kept shut to prevent residents coming to harm College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 7 Care plans must reflect the current needs of residents, including risks, and demonstrate how staff are going to meet these needs. Staff records must be kept at College House to demonstrate the fitness of staff, the training they have completed and further require, and staff competence. Records of interviews must also be kept to demonstrate management decision-making about employment. Staff would benefit from meaningful supervision, that also keeps track of staff training and development needs. There must be a Quality Assurance system at College House to demonstrate that the registered providers are committed to monitoring and improving the quality of care provided. 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 DS0000003674.V279470.R01.S.doc Version 5.1 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 2&4 Prospective residents are given opportunities to make their own minds up about moving to College House, and staff are aware of their needs. EVIDENCE: There was a new resident moving into College House in a few days time. The deputy manager had visited the potential resident, and they had been to College House several times to meet other residents. There was also evidence of a Care Management assessment and an assessment and risk assessment from the residents previous home, however the registered manager had not pulled this information together into their own assessment, risk assessment and care plan ready for when the resident arrived. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6&9 Care plans do not clearly show what resident’s current needs, including risks, are or how care is to be provided and by whom. EVIDENCE: Two care plans were examined in detail and four others looked at less closely. Most residents had a care plan, however many of these plans had not been reviewed, and did not reflect the current needs of the resident. Plans included goals, which was a positive attribute, however again some of these goals had been met, or were no longer relevant. The plans also included photo’s to help accessibility to residents. The deputy manager had worked with each resident in a person-centred way, involving him or her in identifying their care needs using a picture/word and symbol format. However, although these formats were called ‘plans’ there was no information to show how staff, the residents or other people would meet the identified needs, and there was some doubts as to whether staff and residents understood what some of the symbols/areas of need meant. These formats will form the basis of an inclusive way of working, but need more time and thought put into them. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 11 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, which residents were clear about, and said they liked. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 13 & 14 Residents lead active, stimulating, interesting lives within College House and the community. EVIDENCE: Residents have a range of hobbies, and activities in and out of College House including holidays away. They were involved in planning holidays, and talked of trips to Blackpool and Minehead. Residents were also going to a Pantomime in the next few days, and some had already been. At home residents enjoyed art and craft activities, music, rug making, board games, jigsaws and cooking. Some residents attended the local Church, and others used the local community unsupported. Residents spoken to said they had active lives and lots to do. College House DS0000003674.V279470.R01.S.doc Version 5.1 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 the following standard(s): 20 The procedures for administering medication at College House protect residents. EVIDENCE: None of the residents administered their own medication. The deputy manager said all staff administering medication had recently received training, however there were no records to demonstrate this in the home, as these are kept in the Registered Providers office. Medication was being received appropriately, however handwritten record sheets were not being checks and signed by two people as is recommended. Administered medication records were accurate and medication was stored in a locked metal cabinet, however a small quantity of controlled medication was also stored in a metal box, locked inside the metal medication cabinet, but not bolted to the wall. The deputy manager said the Pharmacist had not been concerned about this practice. The administration of controlled medication was recorded correctly. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 23 Residents are protected from abusive situations. EVIDENCE: Since the last Inspection the deputy manager said the majority of staff had attended adult protection training, however there were no training records to demonstrate this, as records are kept in the Registered Providers office. A few staff still needed to attend the course, and a copy of the Local Authority Alerter’s Guidance could not be found. The staff member who had attended the training was able to demonstrate an awareness of what constituted abuse, and what to do if she came across an abusive incident. The other staff member had not attended any training. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 30 The clean and hygienic environment at College House protects residents. EVIDENCE: Those parts of College House seen by the inspector were well furnished, well decorated, homely and clean. However, the deputy manager said they still did not have a maintenance plan that would identify longer term plans, and could be used to inform the Home’s Quality Assurance system. The laundry room had an impermeable floor and washable walls and was clean and hygienic. The deputy manager said staff attended statutory infection control training, however there were no records to show staff training as these are kept in the Registered Providers office. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 16 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 36 The records of newly employed staff were not kept at College House, so there was no evidence that the correct employment procedures had been carried out, potentially putting residents at risk. Although staff were supported on a daily basis by the management, the formal supervision taking place did not benefit staff. EVIDENCE: Two new staff had started work at College House since December 2005, and the only information at the Home about these two staff members was Induction sheets. The deputy manager said interviews had taken place, Criminal Record Bureau checks and Protection of Vulnerable Adult checks had been carried out and application forms had been received but all the paperwork was at the registered provider’s head office. The deputy manager said that interviews did take place however no record is kept of the interview to demonstrate decision making about employment. Staff said they felt supported by the managers, and they were always available for advice. Each staff member was being formally supervised regularly, however the records suggested that these supervision sessions were ‘just going through the motions’ and not benefiting the supervisor or supervisee. ‘As ever’ had been College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 17 written under the heading Training and development issues in one record, which had little meaning or use. Training needs were not being recorded and used to develop the Home’s training development plan and Quality Assurance system, and when issues had been raised there was no record to show what the supervisor had done to resolve the issue. It was suggested that the supervisors attend some supervision training to better understand their role. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 18 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Issues with the storage of toxic chemicals and fire prevention could put residents at risk. There is no Quality Assurance system to demonstrate that College House is continually monitoring and improving its service. EVIDENCE: The registered manager was not present at the Inspection, and had not been present at the previous Inspection, so the Inspector was unable to assess his qualifications, competence and experience of running College House. It was concerning however that of the five requirements made at the last Inspection in August only one had been met. The Inspector will be visiting College House in April 2006 to meet the registered manager and assess progress towards meeting the requirements made at this Inspection. No progress had been made with implementing a Quality Assurance system. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 19 The deputy manager said all staff attended statutory health and safety training, but up to date training records were not available at the Home. The Fire Log book was up to date and appropriate checks, records and training was being provided. The accident book was kept appropriately. There were toxic cleaning products out on top of the washing machine in the laundry, and the cupboard used to store these products was open with the key in the lock. An immediate requirement notice was issued about this risk. The fire door leading to the kitchen was wedged open with a rubber wedge, so again an immediate requirement notice was issued about this risk. A monthly risk assessment was carried out of the environment. College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 20 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 2 X 2 X X 2 X College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 21 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 YA9YA6 Regulation 15 & 13 (4)(b) Requirement Care plans must reflect what support is to be provided and by whom, including support to minimise risks. Care plans must be dated and reviewed six monthly or sooner if a residents needs change. (Previous timescale 30/12/04 & 19/09/05not met) There must be a format for recording staff interviews and decision making about employment. All the required staff records must be kept in the home at all times (Previous timescale 31/01/05 & 19/09/06 - not met) All staff must receive meaningful supervision which helps them carry out their jobs. 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 DS0000003674.V279470.R01.S.doc Timescale for action 31/03/06 2 YA34 18 31/03/06 3 YA34 17 (2) 31/03/06 4 5 YA36 YA39 18(2) 24 31/03/06 31/03/06 College House Version 5.1 Page 22 6 7 YA42 YA42 13(3) 23(4) care (Previous timescale 19/12/05 – not met). All toxic cleaning products must be locked away, with the key removed from the lock. Wedges must not be used in any fire doors. 17/01/06 17/01/06 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 YA2YA9 YA20 Good Practice Recommendations The registered manager should carry out comprehensive needs assessments and risk assessments, including money and medication, before a resident is admitted. Handwritten changes to medication records should be checked and signed by two staff. The controlled drugs box should be bolted to the wall. Records to demonstrate that staff have received sufficient medication training should be kept in the home. A copy of the Alerter’s Guidance should be available to staff, and those staff not yet trained should be. 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. 50 of staff should have at least NVQ 2, and there should be records in the home to show the training achieved and needed for all staff. Action taken by the supervisor on issues identified during supervision should be recorded. Training needs should be highlighted and inform the training needs assessment and plan for the whole staff team. Supervisors should attend supervision training. 3 4 YA23 YA24 5 6 YA32 YA36 College House DS0000003674.V279470.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 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 DS0000003674.V279470.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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