Inspection on 24/01/06 for College House

This inspection was carried out on 24th January 2006.

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

The inspector 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 15/07/08

College House 30/07/07

College House 31/07/06

College House 07/09/05

College House 08/03/05

College House 19/10/04

College House 11/02/04

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE College House 87 College Street Cleethorpes North East Lincs DN35 8BN Lead Inspector Stephen Robertshaw Unannounced Inspection 24th January 2006 09:03 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 DS0000002897.V271533.R01.S.doc Version 5.1 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 DS0000002897.V271533.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service College House Address 87 College Street Cleethorpes North East Lincs DN35 8BN 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) 01472 693957 Mrs Maria Gatt Mrs Maria Gatt Care Home 19 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (19), Physical disability over 65 years of age of places (19) College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 day care place for under 65 with pre-senile dementia Date of last inspection 7th September 2005 Brief Description of the Service: College House is a well-established care home situated in a pleasant residential area in the seaside resort of Cleethorpes: it has good access to local amenities and public transport. The original home was extended and provides accommodation for nineteen service users. The accommodation is provided over two floors and all areas can be accessed by the service users through the use of stairs, a chair lift and a stair lift. There are eight single bedrooms and four double bedrooms at the home. Three of the single rooms include en-suite facilities. There are also two lounges in the home for the service users to choose from and a dining area. The entire home is furnished and decorated to a good standard. The gardens include a pleasant courtyard where service users can sit out. The premises are well maintained and provide a comfortable and homely environment for the service users. The home does not provide intermediate care or nursing care. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 24th January 2006. The inspection was over seven hours and the service users, staff and management were very open and positive in their contact with the inspector. The evidence for this report was gathered through the observation of written records in the home, and the inspectors contact with the service users, staff and management. It also included the inspector’s tour of the environment. What the service does well: The home exceeded one of the National Minimum Standards. This was in relation to the openness and availability of the manager to the service users. Service users stated to the inspector that they are well cared for in the home, and that all of their needs are met through staff supporting them in their dayto-day lives. Service users at the home are provided with chiropody and hairdressing services and personal toiletries free of charge. The individual care plans explain how individual needs should be met. The service users have good access to professional healthcare workers to support their health needs. Records show how service users are supported to maintain contact with their family and friends. All service users have terms and conditions of their residency at the home. Medication policies and procedures are followed by the staff that administer medication to the service users. The staff also receive accredited medication training. Service users legal rights are protected and they are safeguarded from abuse. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. College House DS0000002897.V271533.R01.S.doc Version 5.1 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 DS0000002897.V271533.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 and 5 The service users are provided with the opportunity to visit the home to decide if they want to move there on a more permanent basis. EVIDENCE: The inspector observed the case file information for three of the service users living at the home. Each of the files seen included terms and agreements of the service users residency at the home. This included detail of the room to be occupied, the fees payable and identified who was responsible for funding the placement. The individual service users case files showed that they had received a comprehensive assessment of their needs before they were admitted in to the home. These were a combination of the homes pre-admission information and care management assessment of needs. The assessments covered all of the physical and psychological needs of individual service users. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 9 Interviews with staff, management and discussions with service users confirmed that the home can meet the assessed needs of the service users. Some of the service users stated that ‘the staff are very friendly and helpful’. The staff training programme includes specialist training in relation to the care of older people and associated dementia problems. Service users and staff confirmed to the inspector that service users are invited to visit the home before they are admitted. This allows them to see the home and meet the other service users and the staff group. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 11 The management and staff of the home support and maintain the health and personal care of the service users. EVIDENCE: The quality and content of the individual care plans has improved since the last inspection and all of those observed by the inspector had been evaluated on a minimum of a monthly basis. The individual care plans included clearer detail of how service users needs should be met. The homes care plans covered all of the areas needing support that were identified in the assessment of the service users needs. The care plans were also closely related to the care plans provided for individual service users by their funding authorities. The inspector observed the case file information for three of the service users living at the home. These all clearly identified how service users healthcare College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 11 needs had been met through healthcare professionals that are based in the community. This included contact with GP’s, dentists, chiropodists and district nurses. Each of the care plans seen by the inspector also included an assessment of the service users nutritional needs and service users weight was regularly recorded. The inspector observed the administration of medication to service users in the home. The staff followed all good practice and legal guidelines. The training records in the home supported that staff that administer medication have received appropriate accredited medication training. There were no controlled drugs held in the home. All of the medication record sheets were up to date and were accurately recorded and accounted for. The majority of medication in the home is provided through a local chemist in a monitored dosage system. Returned medications were appropriately recorded and were signed for by the receiving chemist. All of the care plans seen by the inspector included the last wishes of the individual service users in the event of their deaths. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 and 15 The service users are provided with choice throughout their daily lives in the home and in relation to joining in any activities that are provided. EVIDENCE: The service users confirmed to the inspector that they ‘get up’ and ‘go to bed’ at times suitable to them. No pressure is placed on the service users by the staff to go at any other times. The service users can choose which communal area to use and where to sit in it. The service users told the inspector that there were ‘plenty of activities in the home’ and that if they didn’t want to become involved in the activities they ‘didn’t have to’. Adverts for activities were observed around the home. Other service users said that they could attend religious services at the home of they wished to. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 13 Observations also identified that service users had a choice at meal times of what to eat and where to eat it. The inspector ate with a group of the service users. The mealtime was unrushed and the service users said that the meals at the home were ‘always very good’. The meal was well presented and was very tasty. The inspector toured the kitchen and found it to be very clean. The cook had received training in food hygiene and nutritional assessment. No service users in the home required any special diets except low fat or low sugar. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 The homes complaints procedure is easy to access and the service users welfare is protected in the home. EVIDENCE: The management of the home have developed a new complaints policy and produced a new information booklet in relation to complaints. This included the role of the Commission and sample complaints letter formats. No complaints had been recorded in the home since the last inspection. Service users care files included details of who was responsible for their finances through systems such as Power of Attorney or Court of protection. The manager was able to produce evidence that where appropriate service users are registered on the electoral register and are given appropriate support to vote at local and national elections. Interviews with the staff and observation of staff training records confirmed that they receive training in relation to the protection of vulnerable adults. This training is provided through the local authority and is also included in the staff induction training. Staff personnel records showed that thy received the correct safety vetting through POVA first and Criminal Record Bureau clearances before they commenced work at the home. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23 and 24 The environment of the home meets the needs of the service users. EVIDENCE: At the time of the inspection the corridors of the home were being redecorated. New carpets had been fitted, the woodwork had been painted and the walls were in the process of being repapered. Service users stated to the inspector that the home was now ‘much brighter’ than before. The service users stated that they were very happy with the general environment of the home and were looking forward to the corridors being completed. The home had a clear maintenance and renovation plan. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 16 The homes maintenance plan also included the redecoration of six of the bedrooms before the end of the homes financial year. The grounds of the home were well maintained and safe for the service users to use. There is a choice of communal areas for the service users to see their peers, family and friends. One of the smaller communal areas has been designated as a smoking area. The lighting and furnishings provided at College House are domestic in character. New lighting has been included in the corridors of the home. The bathrooms and toilets are well spaced throughout the home and are close to the communal and bedroom areas. Staff training records showed that they now receive infection control training. Thee bedrooms in the home include en-suite facilities. The home has not had an overall assessment of the premises completed by a suitably qualified professional however individual service users case files showed that they had received individual assessments for their mobility and movement needs. The inspector observed the records for the maintenance of the call system, aids, wheelchairs and hoists. Service users spoken to by the inspector stated that they were ‘very happy’ with their individual rooms and confirmed that they were given the opportunity to personalise their rooms. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Staff working at the home receive the appropriate training to make sure that they can meet the needs of the service users. EVIDENCE: The service users stated that ‘there are always plenty of staff’ available to them at the home and the manager stated that the home uses the residential forum to calculate the staffing hours required to meet the needs of the service users. There are no staff under eighteen employed at the home and no staff under twenty one are even left responsible for the building. The manager and the staff that were interviewed were very positive in relation to NVQ training and are working towards their commitment to 50 of he care staff to have achieved NVQ 2 or equivalent. Currently 39.9 of the care staff have achieved a full NVQ 2 award. A further seven members of staff have registered on NVQ training following the management receiving a grant of £11,000 towards NVQ 2. The inspector observed the personnel files for five members of staff. Together with staff information this information supported that the home operates a thorough recruitment procedure that is based on equal opportunities. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 18 All of the files included an application, two written references, interview records, POVA first and CRB information and personal identity documents. When staff begin work at the home they all receive an individual copy of the General social Care Councils codes of conduct and practice. The induction training for the staff is provided through an external training provider and meets the requirements of the National Training Organisation. Staff interviews and training records supported the evidence in the home that the staff receive in excess of the minimum three days paid training per year and all of the mandatory training is met by the staff group. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,36,37 and 38 The management of the home ensures the welfare and safety of the service users. EVIDENCE: The proprietor of the home is also the registered manager. She has completed the Registered Managers Award and has almost completed the NVQ 4 in care. The manager only has two outstanding units to complete the award. Staff interviews and discussions with service users showed that there are clear lines of responsibility and accountability in the home. National Minimum Standard 32 was exceeded. The management of the home is very open, approachable and inclusive. The service users stated that they could approach the manager at any time and that she always listened to them. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 20 The homes quality assurance and monitoring system has improved from previous inspections and the cycle is almost complete. The manager has developed new quality questionnaires to send out to visiting professionals and service users. A survey was sent out to the service users in January 2006. The manager had intended to discuss questionnaire results and action plans at residents meetings, however records in the home showed that the events had been advertised but were not attended by anyone. The inspector discussed the publishing of the quality assurance returns and actions plans with the manager and she stated that the home has a twiceyearly newsletter that the results could be published in. The home has a clear financial plan that demonstrated its financial viability and included in this was a maintenance and refurbishment plan for the financial year. Appropriate insurance for the home and the company was observed to be in place by the inspector. Staff interviews and supervision records supported the evidence that the staff receive a minimum of six formal recorded supervision periods per year and their supervision includes the philosophy of care in the home, their actual practice and career development needs. The home does not use volunteers or agency workers. The records required by regulation were all seen to be in place and were up to date and were generally accurately recorded. The records of keyworker contact with service users should be improved as the current records for this were not accurate and included general care contact. The manager stated that a new care training package has been purchased for the staff and this includes keyworker training. All of the appropriate health and safety requirements were met by the home. This included regular tests of the fire systems (a new fir panel had recently been fitted) and up to date safety certificates foe the gas and electrical safety systems. All of the moving and lifting equipment in the home was maintained and serviced on a regular basis. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 X X STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 4 2 3 X 3 2 3 College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP28 Regulation 19 Requirement The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ 2 or equivalent. The registered person must ensure that the manager of the home has achieved NVQ 4 in care. Timescale for action 31/07/06 2 OP31 9 30/06/06 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 OP33 OP37 Good Practice Recommendations The registered person should ensure that the home has an effective quality assurance and monitoring system in position. The registered person should ensure that all records in the home are appropriately completed especially in relation to Keyworker contact with individual service users. College House DS0000002897.V271533.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002897.V271533.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. 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