Inspection on 08/07/08 for College House

This inspection was carried out on 8th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

College House 01/10/09

College House 13/07/07

College House 04/01/07

College House 07/10/05

College House 13/12/04

College House 27/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE College House 20 College Road Fishponds Bristol BS16 2HN Lead Inspector Kath Houson Key Unannounced Inspection 8th July 2008 10:00 X10029.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.V364093.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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 DS0000040202.V364093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service College House Address 20 College Road Fishponds Bristol BS16 2HN 0117 9651144 NONE benoograh@hotmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Highcleeve Limited 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 (0) College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Mental Disorder, excluding learning disability or dementia (Code MD[E]) - maximum number of places 6 The maximum number of service users who can be accommodated is 21 2. Date of last inspection 13th July 2007 Brief Description of the Service: College House is a detached Victorian private residential home, which provides accommodation for 21 elderly people. The home’s main objective is to create a family atmosphere in an ordinary home where problems and disabilities are no longer the focus of attention. There are currently a longstanding staff team with waking/sleeping night staff to provide 24-hour care. The home can be found in College Road, Fishponds. The house has been extended over the years to provide further accommodation. There are 21 bedrooms 11 of which are en-suite and arranged over two floors. The communal areas include three lounges, which are colour coded; one of the lounges overlooks the garden, which is well maintained. There is a large dinning room where residents can have their meals together. There are enough bathrooms, which contain appropriate aids and adaptations for residents. There are enough parking spaces for numerous vehicles. The home is internally and externally well maintained. The Fishponds area of Bristol has easy access into the town centre; there are bus routes into Yate, Kingswood, Hanham and the surrounding neighbouring areas. There are a number of facilities, which can be found such as pubs, library, shops, and bingo houses. The fees are arranged according to resident’s individual assessment. The fees for a placement at College House range between £370-£400 per week for a total care package. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 5 The home is privately owned and managed by Mr and Mrs Oograh who are responsible for the décor and maintenance of the property. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is adequate 1 star. This means the people who use the service experience adequate outcomes. The judgements that are in this report have been made from evidence collected together during the inspection. This unannounced inspection lasted 1 day and involved a visit to the service. The manager, staff team and residents, health professionals and relatives helped with the inspection. We did this by: • • • • • Looking at the home’s written records. Tracking the care of three people living at the home to see how well their individual needs are being met. Talking with the manager and staff, relatives’ health professionals and residents. The residents, health professionals and relatives sent in their completed surveys. A tour of the home to look at how the accommodation meets the residents’ needs. Getting the views of relatives, residents living in the home and professionals such as the local Dr and members of the staff team. The surveys and informal discussions also gave information that supported the inspection visit. Feedback from the surveys was sent into the Commission and has been included throughout this report. What the service does well: The service provides care for elderly residents who are well cared for in an individualised and consistent way. The staff team are good at helping them to make choices. One resident said, “Gives consideration to everyone not just some”. Provides accommodation, which is comfortable, homely, and free of any offensive smells; residents said, “the home is always clean and fresh”. Good standards of care exist which ensures that residents needs are met. “Provides good overall facilities care & understanding of individuals” The home is managed well with a team of long-standing staff who have good knowledge of the residents to help with giving care and support, “Always caring considerate to clients even when dealing with difficult circumstances they are always patient & considerate”. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents are given enough information to help with the decision making of their choice of home. The admission procedure is detailed and the gathering of information is thorough which ensures that only people whose needs can be met are admitted into the home. EVIDENCE: There have been two new admissions into the service since the last inspection. The home’s Statement of Purpose provides potential residents the information they need to make an informed choice about where they wish to live. This was later confirmed by residents spoken with who said “ I came here to try out the College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 10 home first, and I spoke to a relative who was already in the home and they told me all about it”. The statement of purpose is specific to the characteristic of the home and the residents whose needs can be met; the Statement of Purpose is also detailed in its content and was recently updated in May 2008. The details include the objectives of the home, the quality of the accommodation, the staff structure and the admissions criteria. The new residents each had terms and conditions contract in their file; which outlines the role and responsibility of the provider and the rights of the potential resident. The residents each had signed their contract, which was seen during the inspection. This shows that the residents were included in the decision making for their choice of home. The new admissions had an assessment of needs carried out. This was evident in the files which were examined during the inspection. The manager said that they have a strict admissions policy and only admit those whose needs can be met and who meet the requirements of their registration. For example the home admits people who are elderly and over the age of 65 with mental health needs. The service also provides respite care on a temporary basis for those who wish to have short-term break. The service follows their admissions criteria, which assesses the suitability of the potential residents to the home. The assessments include state of mental health, allergies, dietary requirements, sleeping habits, interest and hobbies, religious views and medication. Selected residents files showed that these assessments have taken place. The residents are also involved in the assessment process and have signed the documents to show that they too were included in their choice of residence. One resident said “my relative came and looked at the home and thought it very good”. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 &11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have clear individualised plans of care, which contain guidelines for the staff team to follow. A good medication procedure exists which protects residents from errors with their medicine. Residents would benefit from an end of life plan, which would ensure that their requests are handled with sensitivity and respect. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 12 EVIDENCE: Four care plans were selected and found to be person centred with risk assessments in place. The resident’s plan sets out in detail the action staff need to take in order to meet resident’s needs. For instance if residents have a disturbed sleep pattern the care plan has guidelines on how to deal with sleep patterns; this is based on the assessment of needs and the gathering of information which was carried out before admission into the home. Residents were also involved in the planning of their care, this was evident, and signatures were seen in their care plans. A health professional was visiting the home at the time of inspection and said, “The home has a good relationship with the local General Practitioner (GP) surgery”. The homes Annual Quality Assurance Assessment (AQAA) states “We could improve on the terminology in our care plans, by removing any medical jargon and writing in simple English, for all staff and service users to understand”. The selected care plans seen were easy to understand and jargon free. The home’s accident and incident book contained clear and well documented accounts of any accidents that had happened in the home. The manager must continue to notify the Commission of any serious head injuries that occur as a result of a fall. This is to make sure that regular information about residents welfare is maintained in times of distress. Some Regulation 37 Notices were seen but there had been some very recent incidents where falls had taken place and a Regulation 37 had not been sent into the Commission. For instance; 26/03/08 resident incurred an head injury, 04/04/08 another resident sustained a injury to her head. Although steps where taken such as the Dr was called and the accident was logged it is required that the service notifies the Commission without delay of such incidents. Resident’s healthcare needs are fully met. For instance, during the inspection the District Nurse was available for comments. It was also evident in residents care files that they can have access to healthcare support on a flexible basis. The healthcare professionals were complimentary about the service and said, “it’s a good home” the residents spoken with also said, “the staff call the Dr and the Dr has all the information, the home is good at sharing the information with the GP”. Monthly updates are currently being started and were seen in some of the files. The staff must ensure that this is consistent for all residents and the monthly accounts are regular. There was also good monitoring of residents weights and this was consistent in the selected care plans seen. On appearance the residents looked well groomed and clean; the staff were seen speaking respectfully to the residents in a calm manner this was also evident from another comment that was made by a health professional “the home is very calm and the residents are always well dressed”. Residents are protected by the home’s policies and procedures in regards to the medication procedure. This was evident, as no drug errors had been College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 13 received into the Commission (CSCI); also no omissions were seen in all the residents’ medication charts. The homes medication was well stocked and stored in a safe place. Only members of staff who are qualified are able to give medication and the manager conducts regular updates with the local pharmacy. Clients who refuse their medication are noted in their medication chart, which provides continual monitoring of residents medication compliance. During the inspection it was noted that the homes British National Formulary (BNF) was out of date. The manager said he would buy a new one. The residents who live at College House are elderly and the average age is 80.5 years. Many of the residents may have a home for life others may move in order to obtain nursing care as a result of changing health needs. During the inspection it was discussed that an end of life plan be arranged. This is to ensure residents at their time of death that their wishes and requests are respected and treated with sensitivity. The aim is for the care and comfort to be handled with respect and dignity and that their spiritual needs are observed and met. This would be especially helpful if residents have to be moved to a place where nursing care is provided during their time of death. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents participate in activities of their choice and interest, which helps them to lead meaningful lifestyles. Good relationships with families and friends are encouraged and maintained. Residents enjoy balanced and varied meals with specialist diets catered for on request. EVIDENCE: The residents who use the service are involved in activities of their own choice and interests. One resident said, “ I enjoy quiet time reading the broadsheet College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 15 newspaper”. A relative said, “when I come in they are playing Bingo, big balls and sitting down keep fit, when there’s a birthday they have a cake and balloons and they do this for everybody”. The in-house activities include, nail polishing, bingo, music and movement. The residents have their daily newspapers and magazines delivered to the home. A resident who said, “I have the independent delivered daily and I do have the choice to have a magazine to do the crossword puzzles” also confirmed this. The activities in the home are undergoing a transformation to include more events, such as sing-a-long, memory lane, and old time musicals. The homes AQAA sates “One resident has started doing her crochet knitting, which she has not done for years, and is happy to teach other people interested”. This was confirmed when the resident showed her crochet during the inspection. For those residents who wish to go to church there are occasions when management makes arrangements for the church service to come into the home, which is ideal for residents with mobility problems. Residents are encouraged to maintain contact with their family and friends. This was confirmed when relatives said,“ I can visit anytime,” Residents spoken with said, “My family take me out”. The home is located in a busy area of Fishponds where there are numerous community facilities. Residents said, “I go to Fishponds Park, shopping, I also go to my daughters house”. The menus are varied and include healthy options. One resident said, “ The food is plain, wholesome, eatable and tastes good”. The home has a threeweek rolling week menu, which residents can have throughout the day. Specialist diets are also catered for on request. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a good accessible complaints procedure, which is easily accessible to all residents and relatives; regular POVA updates would protect residents from potential abuse and neglect and would maintain good practice for the resident’s welfare. EVIDENCE: The service has a complaints procedure can be found in the residents care files and on the home’s notice board. The procedure is clearly written containing text and pictorial format. No complaints about the service had been received at the time of the inspection. Residents and relatives spoken with were complimentary about the service, “Provides good overall facilities care & understanding of individuals”. “The care and support they have received has made a tremendous improvement in the health welfare & confidence for both my mother & her sister”. The surveys that were returned to the Commission were also satisfied with the service provision. The feedback from the health professionals state “I consider College House to be one of the most improved Elderly Peoples Home, I have College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 17 dealings with” another health professional said “it’s a brilliant home I am very impressed, they know their clients I would have my mother in there if it were appropriate”. GPs have not received any complaints about the home. During the inspection it was noted that the protection of vulnerable adults (POVA) training updates had not been maintained. The findings were from the homes staff training matrix which show that 7 members of staff had not have an up date since 2004 and others are due updates in the very near future. This was discussed with the manager at the time of the inspection and the evidence was also shared at that time on the inspection; there was no evidence to suggest that there are future dates lined up to meet this training need. It is important to maintain good practice and to safeguard residents from potential abuse and neglect. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, homely environment; that is well maintained. Independence is encouraged in a non-institutional place where residents live together. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home can be found in the residential area of College Road in Fishponds. The property is a detached Victorian two-storey house, which has been extended over the years. The communal areas consist of three lounges, which are colour coded. One of the lounges, known as the “blue room” is a quiet place, which overlooks the well-maintained garden that is mainly laid to lawn. The selected bedrooms seen were individualised, clean and tidy. The residents had their personal belongings such as family photos, books and puzzles where they have the added choice of place to spend quiet time. The fixtures and fittings meet the resident’s needs. Many of the bedrooms have en-suite facilities. Residents said “The rooms are nice, comfortable and I have my personal items”. The bathrooms and toilets are fitted with the appropriate aids and adaptations and have been regularly serviced. The home provides a physical environment that is homely and comfortable. There is a clean and well-organised laundry room. The home was clean and fresh at the time of the inspection and this was also confirmed by the number of surveys, which include residents comments such as, “The home is always clean and fresh”. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from consistent staffing levels, sufficient to meet their needs, and they can have confidence in good staff recruitment and selection processes. EVIDENCE: The residents who use the service speak highly of the staff, for instance one resident said, “ the staff are good and nice”. Relatives said “Individual staff are always prepared to deal with any difficult circumstances on their own initiative and with attention to the concern of all the residents”. Residents are confident that the staff team are competent in their role of meeting their needs. Another relative said, “all the staff are very helpful and treat mum very well”. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 21 There is a long-standing staff team who have been with the home for several years. The staff rota show that the levels of staff have not dropped below resident’s needs and the management team are always available to deal with any complex issues. There are regular handovers during the day, which informs the staff team of events that has happened on the previous shift. The local District Nurse meets the residents clinical needs. The home provides 24hour staff cover with the deputy manager on site. During the night the home has 1 waking and 1 sleeping–in staff to provide care during the night time hours. The skill mix of the staff are currently 50 of the team who have a variety of qualifications including nursing and NVQs at level 2 and 3. This would provide the residents with a consistent team that is well balanced who are able to meet resident’s needs throughout the day and night. The manager was able to show that some updates have been completed such as food hygiene, first aid and medicine administration. The health professionals’ state, “I have observed no evidence to suggest staff are not appropriately trained”. Selected staff files were looked at and a robust recruitment and selection procedure takes place. This ensures that residents are protected by the homes recruitment policies and procedures. The staff files contain an application form 2 written references, Criminal Records Bureau (CRB) and POVA checks were completed before employment and the terms and conditions were available. All new staff follow a period of induction. Although supervision was discussed this was not fully assessed, the staff files do show that supervision takes place every 3 months. It was also discussed that the managers may need to consider establishing regular staff meetings, this would be beneficial as it would give staff the opportunity to discuss matters as they arise; the last staff meeting took place in March 2008. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 23 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and inclusive to residents and relatives alike and the manager has the required qualifications and experience to run the home; the manager, works towards a clear health and safety policy, regular checks are made which ensures that the home is a safe place for both residents and the staff team. An effective monitoring system would help to maintain good practice in the delivery of service provision. EVIDENCE: The current manager has been in the care industry for several years and is a qualified general and mental health nurse. The manager has the required skills, qualifications and is competent to manage the home. Understanding of the key principles, which is person centred approach to care of the residents, was evident in the home. For instance the home is inclusive which means that residents are involved in their healthcare and families can visit at any time of the day. One relative said “I have never had any problems and no cause to worry and my relative has been here for a long while, I have a good relationship with the management all of them are very good and helpful”. Residents, health professionals, relatives have been complimentary about this service throughout the day during the inspection. One health professional said, “Very friendly manager always makes a point of saying your name which adds to good relationships with the Drs surgery”. A relative said, “The management team are very good” this was also confirmed by a relative who said “they are lovely people the manager is very kind”. The manager discussed that the monitoring of the service is the next item on his ‘to do list’. He was able to show a questionnaire that measures the quality of the service that the home provides on a regular basis. The questionnaires are ready to go and he aims to send them out shortly. The manager is aware that he wishes to continue to improve the service for the residents and is making significant steps to continually improve. For instance the outcome of the findings from the survey provides the information to make improvements in the home. This was also confirmed in the home’s AQAA, which states, “We will continue to implement our quality assurance surveys and process the results that we receive, possibly implementing these into our daily running of the home”. The manager also wishes to reinstate residents meetings, which College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 24 would ensure that resident’s views are captured and implemented in the home. Residents funds are kept in a secure place- randomly selected receipts were accurate. The home has consistent record of health and safety checks. This was confirmed by looking at a number of documents such as the homes weekly fire safety checks that were completed and up to date. There was evidence to show that the fire safety officer had some input in the home and has agreed to the safety measures that exists in the home. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 5 3 6 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 26 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 OP18 Regulation 13 (6) Requirement Timescale for action 08/07/08 2. OP33 3. OP37 The registered person must make arrangements to regularly update staff training to prevent residents from being harmed or suffering abuse or being place at risk of harm, this is to ensure that residents are safe from potential abuse and neglect. 24 (1) The registered person must 08/07/08 make arrangements to seek, establish, and maintain a system for reviewing the quality of the service the home provides at appropriate intervals. 37 (1) The registered person shall give 08/07/08 (b,c,d,e,f,g) notice to the commission without delay of the occurrence of any of the matters set out under this regulation including any event which adversely affects the wellbeing or saftey of any service user. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. College House DS0000040202.V364093.R01.S.doc Version 5.2 Page 29 - 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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