Inspection on 07/09/05 for College House

This inspection was carried out on 7th September 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 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 15/07/08

College House 30/07/07

College House 31/07/06

College House 24/01/06

College House 08/03/05

College House 19/10/04

College House 11/02/04

Similar services:

Abbey The

Snydale Care Home

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 7 September 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service College House Address 87 College Street Cleethorpes North East Lincs Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01472 693957 Mrs Maria Gatt Mrs Maria Gatt Care Home 12 Category(ies) of OP (12) registration, with number of places College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions to the homes registration. Date of last inspection 2nd March 2005 Brief Description of the Service: College House is a well established home situated in a pleasant residential area in the sea – side resort of Cleethorpes; it has good access to local amenities and public transport. The home has benefited from an extension in recent years and is registered to take 19 service users with residential care needs; four of those beds are registered for persons with mild to moderate dementia. Accommodation is provided on two floors; there is stair and chair lift access to the first floor. There are eleven single rooms and four shared rooms; three of the single rooms have en-suite facilities. The home has two lounges and one dining room; all rooms are decorated and furnished to a good standard. There are bathroom and WC facilities located on each floor. There is a pleasant courtyard area where service users can sit out. The home is well maintained and provides a pleasant, homely inclusive atmosphere. The home is owned and managed by Mrs Maria Gatt. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. College House was inspected on 7th September 2005. The inspection was unannounced and took place over a period of eight and a half hours. 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. Most of the requirements for the home were met, and the outstanding requirements did not cause any major concerns in relation to the health and safety of the service users. The only exception being that not all new staff received POVA first or Criminal reference Bureau clearances before commencing work at the home. This could place the service users at risk of abuse. What the service does well: What has improved since the last inspection? All of the radiators in the home have now been fitted with low temperature surfaces to protect the service users from the risk of scalds and burns through contact with hot surfaces. The quality of the individual care plans has improved in the home to detail how individual care needs must be met and all care needs were included. A risk assessment accompanies any care plan that includes the use of bed rails, and records are maintained to ensure that the bedrails are properly maintained and serviced. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 6 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 J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 standard(s) 1,2,3 and 4. The home does not provide intermediate care. College House gives choice to potential new service users in how their care can be provided in the home, and in deciding if the home is right for the individual service user. EVIDENCE: The inspector observed the case files for four service users. These records showed that the service users had been assessed by the home before the service user was admitted there to determine if the home could meet their needs. The homes assessment information could be closely related to the individual service users needs that were identified by the care management team that was responsible for their placement. The care management assessments also included detail of the care management care plans including the involvement of the home in the care of individual service users. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 9 All of the service users files observed by the inspector included terms and conditions of their residency at the home. This included the fees payable, and gave details of termination requirements of the residency agreement. Service users at the home are provided with hairdressing and chiropody services free of charge. These services are purchased from an outside provider by the management of the home Service users are also provided with personal toiletries provided by the home, they do not have to purchase these for themselves, and they have choice in relation to receiving the toiletries that they require. Discussions with service users identified that they believed that their care was being met appropriately in the home, and that the home had the capacity to meet their needs even if they changed whilst at the home. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 standard(s) 7,8 9 and 10 The service users are provided with services and care in the home that maintains their health, and personal hygiene. EVIDENCE: The inspector observed the care plans for four of the service users at the home. These had all been reviewed on a minimum of a monthly basis to ensure that the service users needs were still being met, and to identify any changing needs that they may have. The home does not provide nursing care, however wherever individual service users had healthcare needs their files showed how other professionals were involved in supporting the home with their needs. This included contact with the district nursing team, GP’s and hospital specialists. Service users also confirmed to the inspector that when they are seen by healthcare professionals this is always in private unless they request support from a member of staff. Private chiropody services are provided in the home at no cost to the service users. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 11 The prescribed medication was stored appropriately, and the inspector’s observations provided evidence that the service users were given the correct support to receive their medication. In all but one instance the medication was appropriately recorded. The only failure in the medication procedures was in relation to a service user receiving Paracetemol (PRN). This had not been recorded on the MARS record sheet for a period of one week. Discussions with service users provided evidence that they have access to a public telephone at the home and that they always receive their own clothes back from the laundry. The inspector’s observations also provided evidence that the service user in the home are treated with dignity and respect at all times. Service users also confirmed this information to the inspector. Service users also stated that the staff always knock on their bedroom doors before entering. Service users diary records showed that they are supported and encouraged to maintain and develop their relationships with their family and friends that live outside of the home. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15 The service users are supported in the home to make decisions and choices for themselves in relation to their daily lives and the social activities that they become involved in. EVIDENCE: The activities that are available to the service users at College House are limited in relation to the range of activities and the frequency that they occur. This was countered through the inspectors discussions with the service users. They stated that they were happy with the frequency and content of the activities that were available in the home, and that they did not have to become involved in any activities that were being provided if they did not wish to. The service users also stated that if they did not become involved in activities the staff still made sure that the service user were occupied in the way that they chose. The inspector’s observations also supported that choices are made available to the service user throughout the day at the home. This included whether or not to become involved in activities, and what to eat at mealtimes. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 13 Visitors to the home spoken to by the inspector stated that they are always made to feel welcome at the home, and that they can visit at any reasonable time. The visitors also stated that where appropriate they were invited to the reviews of the care of service users at the home to ensure that the service users needs were being met, and to help to identify if any of their needs had changed since the last review of care. The inspector ate lunch with the service users. This was well presented and very tasty and a choice of meal was available. The service users that the inspector sat with stated that the quality of the meals that are provided in the home was always very good and ample portions were always given. Service users stated that if they wanted a small meal or a large meal them this would be provided. Service users also said that they are often asked what they would like to be included on the menus at the home. The menus were provide over a four week period and evidenced a variety of nutritious meals. The home provides four meals a day including supper. A hot choice of meal is often available at suppertime at the home. An inspection of the kitchen found it to be very clean, and there were plentiful supplies in the food stores. The cook was responsible for maintaining the food stock and arranged through the homes manager to obtain new supplies. Care plans identified preferred times for rising from and retiring to bed for individual service users. Service users stated that although they had preferred times to rise and retire in their care plans the staff at the home always checked with them to make sure that they didn’t want to choose to get up or go to bed at later times. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 standard(s) 16, 17 and 18 The home makes sure that the service users understand how to make a complaint about the service that they receive if they are not happy with it. New staff to the home had not all received appropriate safety clearances. This could place the service users at risk of abuse. EVIDENCE: There had been no complaints recorded in the home since the last inspection and no complaints had been sent directly to the Commission for Social Care Inspection. The records in the home showed that where appropriate service users are included on the electoral register and are supported through the staff at the home to vote at local and national elections. The home does not hold financial responsibility for any of the service users that live there. Individual service users case files showed where they receive financial support from either their families or solicitors and where appropriate where this is managed through the Power of attorney. Staff personnel records indicated that they had not all received the appropriate safety clearances before commencing work at the home. This could place the service users at risk of possible abuse. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 standard(s) 19,20,21,22,25 and 26 The service users are provided with a clean and homely environment. There are a variety of communal areas that they can choose to use to socialise with their friends and family when they visit. EVIDENCE: The service users spoken to by the inspector stated that they felt safe in the homes environment. The staff at College House receive training to ensure that they can maintain the safety of the service users. This includes moving and handling, risk assessment and Control of hazardous substances and health and safety training. The staff had not received infection control training but this was identified in the homes training and development plan for the current year. There were some infection control concerns on the day of the inspection. Blocks of soap, and linen towels had been left in the homes bathrooms and College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 16 toilets. This was raised with the manager by the inspector and these items were immediately removed and disposable towels, and liquid soap and dispensers were purchased and placed in all of the bathrooms and toilets. The bathrooms and toilets are spaced around the home and are close to the bedrooms and communal areas. The home also includes three en-suite bedrooms. There are different communal areas in the home. The female and male service users tend to choose to isolate themselves from one another in different lounges. Service users spoken to by the inspector stated that the communal areas that they were in were their choice and they were not directed there by the staff. The laundry at the home includes washing machines that are programmable to sluicing and disinfection standards. The home regularly records the hot water temperatures at the outlets and these indicated that the temperatures are regulated close to 43 degrees Celsius. The inspector randomly sampled the hot water temperatures and this indicated some variance in the water temperatures. A tour of the premises by the inspector found that it was very clean and tidy and there were no bad smells in any area of the home. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 There are appropriate numbers of staff available at the home, and they receive appropriate training to make sure that they understand and can meet the needs of the service users at the home. EVIDENCE: The inspector observed the staff rotas, and spoke to the service users about the staff. The service users stated that there was always enough staff at the home to meet the needs of the individual service users interviewed. They also said that if they activated the call button the staff were always quick to respond. The staff were observed to be very courteous to the service users ensuring dignity and respect were upheld at all times. Service users confirmed to the inspector that this was the general practice at the home. The management and staff of the home are committed to achieving the minimum of 50 of the care staff to have achieved NVQ 2 or equivalent by 31st December 2005. Currently 36.8 of the homes staff have achieved NVQ 2 in care and a further 12 members of staff are registered on the award and are working towards its completion. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 18 The homes recruitment procedures meet most of the required standards. However a recently appointed member of staff had not received clearance from either POVA first or the Criminal Reference Bureau before commencing work at the home. This action could place the service users at risk of abuse. New staff to the home receive induction and foundation training which meets the requirements of the National training Organisations workforce training targets. This ensures that the staff can fulfil the aims and objectives of the home and meet the changing needs of the service users. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,37 and 38 The management of the home provides an open and inclusive atmosphere and works to ensure the health and safety of the service users. EVIDENCE: The manager of the home is working towards the Registered Managers Award and has completed seven of the required units. She has also completed NVQ 2 and 3 in management and is currently working towards NVQ 4 in management. Discussions with service users and interviews with staff confirmed that the management of the home is very approachable and that the management listens and takes notice of what they say. The standard for the openness of the management of the home was exceeded. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 20 The home has a quality assurance and monitoring system to identify the quality of service that it provides to service users. A quality audit is completed every month and this includes questionnaires to service users carers, and outside professionals. This system needs to be developed further to included an analysis of the information received back from the questionnaires, an action plan must then be developed and the results must be made public. The business and financial plan for the home projected the homes expenses for the forthcoming financial year of the home. Service users monies in the home were well recorded and accounted for. Service users that were not responsible for their own finances had this identified in their care plans. The care plans also indicated who was responsible for their finances and if this was through any legal requirements such as the Court of Protection or Power of Attorney. New policies and procedures had been developed at the home for the safe use of bedrails. Staff interviewed clearly understood these procedures. The records for the protection of the service users were all appropriately recorded and up to date. The health and safety requirements of the home were generally met. This included up to date safety certificates for the gas and electrical systems in the home, PAT tests, emergency lighting and call system monitoring and maintenance and all of the appropriate fire safety requirements. The inspector also observed the records for the maintenance and servicing of the homes moving and handling equipment. Staff training records provided evidence that they receive first aid and moving and handling training. Since the last inspection thermostatic valves have been fitted to all of the hot water outlets at the home. The blue carpet in the corridor next to the managers office is in need of repair or replacement to ensure the safety of the service users and to prevent trips and falls. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 x x 2 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 1 2 4 2 3 3 x 3 3 College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 22 NO 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 18 and 29 Regulation 19.1 a Requirement The registered person must ensure that all staff working at the home have appropriate CRB and POVA first clearances before commencing work at the home. The registered person must ensure that a minimum of 50 of the care staff have achived NVQ 2 or equivalent. The registerted person must ensure that the manager of the home has achieved the REgistered Mananagers Award or equivalent. Timescale for action 08/09/05. Applicable to all new staff to be employed at the home. 31st December 2005 31st December 2005. 2. 28 18 3. .31 9 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 The registered person must ensure that all PRN medication in the home is recorded as administered or an approprite entry is mnade in the records when the PRN medication is not administered. The regiostered person must develop the range and J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 23 2. 12 College House 3. 4. 5. 21 25 33 6. 38 increase the frequecy of activities that aree available to the service users at the home. The registered person must ensure that all staff working in the home recieve infection control training. The registered person must ensure that the new thermestatic valves on the hot water outlets are monitored and maintained close to 43 degrees celsius. The registered person must continue to develop the homes quality assurance and monitoring system to ensure that it identifies and plans for any changing needs in the services that are provided by the home. The registered person must repair or replace the blue carpet on the corridor outside the managers office to ensure the health and safety of the service users and to protect them from trips hazards and falls. 7. College House J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire 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 J54 College House UI 070905 v247053 s2897 Stage 4.doc Version 1.40 Page 25 - 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!