Inspection on 07/10/05 for College House

This inspection was carried out on 7th October 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

College House 01/10/09

College House 08/07/08

College House 13/07/07

College House 04/01/07

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 7th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address College House DS0000040202.V255132.R01.S.doc Version 5.0 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.V255132.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service College House Address College House 20 College Road Fishponds Bristol BS16 2HN 0117 9651144 NONE 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.V255132.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 Install a gate at the side of the house where the pathway leads directly from the garden onto the main road in order to ensure the safety of service users with confusion. Seek the advice of an Occupational Therapist regarding the exit from the new lounge into the garden where a step with a small lip may be a hazard to those less mobile service users. 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. 20th April 2005 4. 5. 6. 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. This also applies to the conservatory, which looks out onto a very attractive garden with lawns, shrubs and trees. 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 has recently been renovated to include a new extension to accommodate up to 4 people with mental illness. This addition to the building has provided 4 new bedrooms with en-suite facilities and also includes a new lounge and shower room. College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is the second unannounced inspection of the 2005/06 inspection year. It was conducted over one day in October 2005. There have been no additional visits to the home since the last inspection. During the inspection visitors to the home were consulted on the standards of care observed. Residents and staff agreed to give feedback on the service provision at the home. What the service does well: What has improved since the last inspection? College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 6 Since the last inspection the service provider has taken the necessary steps to comply with conditions of registration based on improvements to the external environment. This has made the property a safe place for residents. 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 DS0000040202.V255132.R01.S.doc Version 5.0 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.V255132.R01.S.doc Version 5.0 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): 1, 2, 6 The Statement of Purpose does not fully inform potential residents about the home. It needs entries about the arrangements for respite care, promoting privacy and dignity, confidentiality, and security of records to do so. The home’s terms and conditions provide all necessary detail apart from confirming the room each person will be entitled to occupy. EVIDENCE: Reference to the Statement of Purpose is made in relevant sections of this report. The requirement to include the room number in the statement of terms and conditions has not been actioned. College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 9 Intermediate care is not provided at the home. Respite care is offered whenever vacancies exit but the Statement of Purpose does not include a description of the arrangements available for respite care. College House DS0000040202.V255132.R01.S.doc Version 5.0 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, 9 & 10 Care plans must be detailed to provide sufficient information to help staff meet residents’ needs. Within the action plan residents likes, dislikes and preferred routines must be incorporated to provide the basis for the delivery of care. For people with mental health needs, triggers for deterioration of their mental health need to be included. Where possible, residents’ involvement in and agreement with their plan of care must be evidenced – for example, through signature on their care plan. Risk assessments do not lead on to an action plan about how any identified risks to residents will be minimised. Controlled drugs procedures should be adopted for benzodiazepines and the records of homely remedies must be accurate and up to date so that residents are fully protected by the home’s medication administration practices. Residents feel they are treated with respect and that their right to privacy is upheld although a policy based on Privacy and Dignity must be devised and summarized in the Statement of Purpose to reflect the established practices at the home. College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 11 EVIDENCE: Care plans are in place and detail the individual assessed needs, with an action plan for staff to meet the needs. However the action plan is brief and must be further developed to be sufficiently detailed to offer guidance to maintain consistency of care. Although residents’ likes, dislikes and preferred routines are sought during the assessment process, they are not clearly incorporated into care plans and reflected in action plans. Care plans are not signed to evidence that residents have meaningful input into the decisions about their care. Risk assessments are in place for residents that require assistance with manual handling. Members of staff are instructed, during their induction, on the principles of care operating at the home, to establish the approach towards residents’ rights. However, there is not yet in place a policy based on residents rights to privacy and dignity, which would reinforce the established practices of the home. The elements that demonstrate residents rights are respected at the home include a pay phone available and a cordless phone for more private conversations. During the admission process residents preferred mode of address and recorded in their case records. Residents giving feedback confirmed the home’s approach towards respecting their rights. Members of staff knock and wait for an invitation to enter bedrooms. Personal care tasks are conducted in private with the door closed. Downstairs bedrooms are single and lockable. It was understood from the service provider that there is a programme for installing locks in the bedrooms upstairs. A monitoring system for the administration of medications was recently introduced. The records examined indicated the medications records are signed immediately after administration. It was noted during the examination of the records that benzodiazepines are administered. It is strongly recommended that controlled drugs procedures are adopted for the monitoring of balances kept at the home. Homely remedies are administered from a stock supply when required by the residents. Inaccurate recording was found for the balances of analgesics. College House DS0000040202.V255132.R01.S.doc Version 5.0 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, 13 & 14 Care plans must incorporate residents likes, dislikes and preferred routines to ensure that residents have opportunities to exercise choice about their daily living. Residents visitors ensure that links with family and friends are maintained. The service provider takes steps to ensure residents have personal autonomy. Residents control their finances, have personal possessions in their bedrooms and their records are kept secure. To confirm the practices, a policy on Confidentiality must be devised. EVIDENCE: During the admission process, residents likes, dislikes and preferred routines are sought. From the assessment individual weekly activity programmes are developed. Watching television, listening to the radio, scrabble and bingo were included in the planners. Within the planner visits from friends and family are listed and visitors book evidenced that residents have visitors. In-house activities are generally organised in the afternoon. Daily reports detail the group activities undertaken along with the names of visitors to the home. For example, discussion group about current affairs and Bingo. Residents comments supported the home’s policy for visitors. Visitors to the home are College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 13 welcome and visits can take place in bedrooms for additional privacy. Bingo took place during the inspection and residents were observed joining the activity. A visitor to the home agreed to give feedback on the provision of care observed. It was reported that whenever visits to the home take place, the staff make time to discuss all aspects of their family members lifestyle. The visitor further commented that there are consistent standards of care observed during each visit. A statement about the arrangements for the safety of records kept at the home must be included in the Statement of Purpose. Access and security of records along with sharing information must be added. Guidelines must follow Data protection and must describe the implication to staff for breaches of confidentiality. Within the admission procedure, the home’s rule on personal possessions is described. Residents giving feedback confirmed that they can bring personal possessions when they move to the home permanently. One resident stated that her family had completely redecorated her bedroom and purchased the furniture for the room. The residents currently accommodated have full control over their finances. College House DS0000040202.V255132.R01.S.doc Version 5.0 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 Residents reported that their views are sought and acted upon. EVIDENCE: There were no complaints received at the home for investigation and four letters of compliments were received about the service, since the last inspection. Residents consulted about the care, stated that the service provider and staff would be approached with complaints. Confidence that their concerns would be taken seriously was also expressed. College House DS0000040202.V255132.R01.S.doc Version 5.0 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 & 26 College House is maintained to a good standard, offering a comfortable and homely environment. The premises are clean and free from unpleasant smells. 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. The property is well maintained both internally and externally. The standard of décor is good and residents felt there was a high standard of hygiene. College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 16 The service provider has taken steps to comply with the imposed conditions of registration. A gate was installed, where the pathway leads directly from the garden onto the main road. To further ensure residents’ safety, a wooden gate was fitted to the stairwell that leads into the basements. At the rear of the property a ramp was installed on both sides of the door to remove the potential of a trip hazard. 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 home was clean and free from unpleasant smells. Residents and visitors felt that there is a good standard of cleanliness at the home. College House DS0000040202.V255132.R01.S.doc Version 5.0 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, & 30 The staffing levels in place are suitable to meet the current residents’ range of needs. All members of staff must attend dementia and mental health training to competently meet the registered category of needs. EVIDENCE: The rota in place indicated that the manager, three care assistants and ancillary staff are rostered between 8:00 and 1:00 pm. From 1:00 pm there are three staff with the deputy, staffing levels then fall to two staff from 6:00 pm. At night there is one person awake and two sleeping in the premises. The training programme in place includes the statutory training, specific instruction for the registered category of needs and vocational qualifications that match the expectations of the National Minimum Standards. Members of staff must attend First Aid, Food Hygiene, and Infection Control, Moving and Handling training. POVA and medication training is also included in the home’s rolling programme of training. College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 18 Two staff have completed NVQ level 2 and two are currently undertaking this award. Two staff have attended dementia and mental health training. As the home is registered to accommodate people with dementia and mental health care needs, all members of staff must have specific training to meet their needs. College House DS0000040202.V255132.R01.S.doc Version 5.0 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): 35 Records of fees and cash held in safekeeping ensure that residents’ financial interests are protected. EVIDENCE: Individual schedules that detail the fees and sources that contribute to the weekly charge are in place for local authority placements. . For residents that self-fund, contracts are in place. Records indicate that the fees for local and self-funded placements range from £339.00-£400.00 per week. It was understood from the service provider that fees are paid by direct debit into the home’s account. College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 20 Facilities for the safekeeping of cash and valuables exist at the home. Eleven residents currently have cash in safekeeping and the records were correct and up to date. A description of the transaction, balances and two signatures are included, with receipts to support purchases made on behalf of the residents. College House DS0000040202.V255132.R01.S.doc Version 5.0 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 2 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x x College House DS0000040202.V255132.R01.S.doc Version 5.0 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 2 Standard 2 7 Regulation 5 15 Requirement Terms and Conditions of residency must include the room number. a) Evidence that for self-funded placements, a care planning review process exists. b) For residents with mental health care needs, potential triggers of deteriorating mental health must be included in the care plans. c) Risk assessments must include an action plan to minimise the identified risk. Previously required 20/04/05. Accurate balances of homely remedies must be maintained. Previously required 20/04/05. a) Ensure all staff have a recent photo in their personal files. b) Staff must provide a written statement about their physical and mental fitness. Previously required 20/04/05. DS0000040202.V255132.R01.S.doc Timescale for action 31/12/05 31/01/06 3 9 13(2) 30/11/05 4 29 19, Schedule 2 31/12/05 College House Version 5.0 Page 23 5 5 4(1)(c) The admission criteria must be added to the admission procedure. Previously required 20/04/05. The Statement of Purpose must summarize: a) the arrangements for respite care. b) the home’s policy on promoting Privacy and Dignity. c) the home’s policy on confidentiality. d) the home’s policy on promoting security of records. a) Care plans must incorporate the likes, dislikes and preferred routines of the individual. b) Where possible, residents’ involvement in and agreement with their plan of care must be evidenced – for example, through signature on their care plan. Members of staff must attend dementia and Mental health awareness training. 30/11/05 6 6 4 31/12/05 7 7 12(3), 15(1) 31/01/06 8 30 18(1)(c) 30/09/06 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 Refer to Standard 9 Good Practice Recommendations Adopt controlled drugs procedures for the monitoring of balances of benzodiazepines kept at the home. College House DS0000040202.V255132.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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