Inspection on 12/02/07 for College House Residential Home

This inspection was carried out on 12th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

College House Residential Home 17/09/09

College House Residential Home 03/03/09

College House Residential Home 09/09/08

College House Residential Home 15/02/06

College House Residential Home 06/09/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE College House Residential Home Berrington Road Tenbury Wells Worcestershire WR15 8EJ Lead Inspector Rachel McGorman Unannounced Inspection 12th February 2007 11:30 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 Residential Home DS0000064821.V327390.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. 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 Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service College House Residential Home Address Berrington Road Tenbury Wells Worcestershire WR15 8EJ 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) 01584 810270 01584 811822 Oaktree Care Ltd Vacancy Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12), Old age, not falling within any other category (12), Physical disability over 65 years of age (12), Sensory Impairment over 65 years of age (12) College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: College House is situated in the town of Tenbury Wells within easy walking distance of the shops and local amenities. The house dates back to 1698 and has been upgraded and adapted to provide comfortable accommodation. The home is registered to provide residential care for up to twelve older people who are active, who may have a physical disability or who may have a mental health problem. College House is also able to provide limited day care, when requested, respite care, when a bedroom is available, and support to residents living in adjacent bungalows. The range of fees varies between £350 and £450. The stated aim at College House is to provide considerate and skilful care in comfortable and homely surroundings, where people are able to enjoy a contented lifestyle, with the assurance that their individuality, independence and personal dignity will be respected. College House was purchased by Oaktree Care Ltd. in January 2006, and Mrs Joan Pressdee is registered as the Responsible Individual. Mrs Margaret Hope, who was the registered care manager for the last 3 years resigned recently, and Ms Claire VanLooy, as the acting manager, now has responsibility for the day-to-day running of the home. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. Preparation for the inspection included viewing previous reports, and documentation relating to the home, and considering the various contacts with the home since the last inspection. The pre inspection questionnaire provided updated information about the establishment, and any recent changes that have taken place. Comments were received from service users, and their families or a representative in response to surveys that had been sent to them. The views of health and social care professionals in contact with the home were also sought. The visit was unannounced and took approximately 6 hours, when some time was spent with service users, discussing with them what it is like living at the home, and observing interactions between residents and staff. The care records of two service users were checked in detail for case tracking purposes, and the Medication Administration Records were also seen. During conversations with staff, comments were made about what it is like to work at the home, and the training opportunities that are available. The files of two staff were also seen. Discussions were held with the Acting Care Manager, Ms Claire VanLooy, about her role, and the day-to-day management of the home. A tour of the building was undertaken, and recent developments, and future proposals for maintaining and upgrading the home were discussed. The records relating to the servicing of equipment, and to health and safety matters, including the fire log and accident reports were also seen. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 6 What the service does well: College House provides a warm welcome to everyone, and the atmosphere is homely and relaxed. Several of the residents said they were comfortable and very happy to be living there. The home is very much part of the town of Tenbury Wells, and involvement with the local community is actively encouraged. Some service users are able to walk into town, while others are enabled to access the shops and local facilities when they wish. A neighbourly service is provided to people who live in the vicinity of the home, and a meals on wheels service is also organised, which covers the local areas. Day care can be arranged at the home, and residents are also able to access the local day services. Relevant information about the service, and what can be provided, is available to service users and their families, and is reviewed regularly to ensure that it is up to date and accurate, and therefore able to assist prospective residents and their families to make the right decisions about their care. A culture of providing good care has been developed over the last twenty five years at College House, and is still being maintained. The home very obviously revolves around the residents, and the mutual respect and consideration shown by everyone is pleasing to observe. A high standard of personal and health care is provided for each resident at the home, and the staff work well with other professionals and agencies, to help improve and maintain the health of service users, with obvious benefit to them. Opportunities are available for service users to do various activities, and they are able to choose if they wish to be involved. Transport is available to enable service users to maintain contacts outside the home, and some people enjoy visiting the local garden centre for tea occasionally. Recruitment and selection procedures are in place, and the management is clear about the support, training and development for the staff it employs. Staff confirmed that they are given appropriate training opportunities. Residents describe the care they receive as good and the food as lovely, and comments from relatives confirmed that College House is a happy home, and that staff are kind and helpful. The building has been sensitively extended and upgraded, and is maintained to a high standard. It is nicely furnished, warm, comfortable, safe and clean. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? There is an obvious commitment from everyone involved with the provision of care at the home, to the ongoing improvement and development of the service, for the benefit of the people who live there. The protection of service users has been promoted by the improvements seen in the administration of medication at the home. The Medication Administration Records are now being completed to a satisfactory standard. Service users confirmed that they knew about the complaints procedure at the home, and said they felt that their opinions were welcomed, and that any concerns would be dealt with. One person said they didn’t have any concerns. Training has been provided for staff on bereavement and the Protection of Vulnerable Adults from abuse, and further training courses are planned. An individual training and development assessment and profile has been produced, and should ensure an effective and competent workforce. Some areas in the home have been redecorated and new carpets fitted, new furnishings have been provided, further development of the laundry undertaken and several items of equipment have been replaced, to ensure that standards are maintained within the home. The Fire Risk Assessment has been completed, and an Emergency Evacuation Contingency plan is in place at the home, which will ensure that appropriate action will be taken to protect service users in the event of an emergency situation occurring. Notifications under Regulation 37, which requires reports to be sent to the Commission of the death, injury or serious illness of a service user, or other events in the home, are now being submitted when necessary. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 8 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 Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 9 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 Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate information is provided for prospective service users, to assist them in making a decision about their future care needs The pre-admission assessment ensures that the home is able to meet the identified needs of service users, although would benefit from being more detailed. The admission procedure provides a satisfactory introduction to the home for service users, and regular reviews will reassure them that the home is able to meet their needs. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 11 EVIDENCE: A statement of purpose has been produced, which together with the service users’ guide, provides prospective residents with the relevant information to enable them to make a decision about their future care needs. These documents are reviewed annually, the next review being due in April. The Statement of Purpose has been produced in large print, and can also be provided on audiotape for service users who may have a sensory impairment. A statement of the Terms and Conditions of residence is provided to each service user on admission, and contains relevant information about their occupancy. Following the initial referral, a pre-admission assessment is undertaken by the care manager, either at home or in hospital, before any decision is made. The documents seen in the files of service users contained relevant information, although a more detailed assessment would better enable staff to decide if the needs of prospective residents could be met appropriately at the home. There is a well-established admission procedure in place. Prospective residents are encouraged to visit the home, and to spend time with the resident group, and also stay for a meal. Arrangements may also be made for a short stay, if this is preferable, before making a decision about future care arrangements. One service user who transferred to College House from another home said she would have preferred to have been given more time to get used to the idea of moving, but she was aware that because she had been very poorly they were unable to continue to meet her needs at the previous home. She had made some good friends when she was living there, and hoped that it may be possible to return, as she was now in much better health. The acting care manager confirmed that a review was to be arranged to consider this possibility. Intermediate care is not provided at College House Residential Home. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 12 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. 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. The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Risk assessments are completed, to support service users to be as independent as possible, although they should include all the activities of daily living. The procedures followed in the administration of medication ensure the protection of service users. The privacy and dignity of service users was respected, and the atmosphere throughout the home was one of mutual esteem and regard. Training is provided for staff to ensure a greater understanding of the issues regarding death and bereavement. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 13 EVIDENCE: The Training Masters System of care planning is in use at the home, and covers the health, social and personal needs of service users. An individual plan of care is produced for each service user, which is based on the initial assessment undertaken at the time the service user is admitted to the home. Evidence was found in the files of service users that they are involved throughout the process, and this includes on-going assessment and review, but the need for these reviews to be undertaken at least monthly was discussed with the acting care manager. The record is signed by the resident, and their key worker, and also the care manager. A mobility risk assessment is completed for each service user, and risk assessments relating to nutrition and tissue viability are also undertaken depending on their specific needs. Two files seen by the inspector also contained mental health assessments, and details are recorded about the involvement of the Community Psychiatric Nurses, who support the staff in their care of these service users. The health care records seen during the inspection, clearly indicate that the health and personal care needs of service users are monitored and relevant action taken. The home is well supported by the Primary Health Care Team, and referrals are made when necessary, e.g. to the continence advisor. A satisfactory medication policy and procedure is in place, although the guidelines for the administration of PRN (when required) medication are to be reviewed. The home receives support and advice from the Pharmacist, who visits the home every three months to monitor the medication procedures. The Medication Administration Records (MAR) have been completed to a good standard, and training has been provided for staff. One service user is supported by staff to manage his medication, and a risk assessment has also been completed, therefore he is able to retain some independence in this area. Evidence to indicate that service users are treated with dignity and respect was observed in the interactions between staff and service users, and was also confirmed in discussion with several residents. Their comments included: • • • • • • • The staff are very good I’m happy living here The staff are usually around when I want them I’m quite satisfied with my care The cleaners keep the home looking nice The doctor can be contacted at any time The meals are very good DS0000064821.V327390.R01.S.doc Version 5.2 Page 14 College House Residential Home There were a couple of issues brought up by service users, which were referred to the acting manager for action to be taken: Firstly, several people mentioned a new bath seat that has been fitted to the bath on the first floor, which they do not like because it does not lower them into the water. A ‘medic’ type bath is available on the ground floor, which allows service users to be immersed, and to soak for a while, if this is what they wish, but the comments about this facility were not very positive either. The acting manager agreed that the situation should be reviewed. A further issue of concern was that the footrests are removed from wheel chairs. This practice is unsafe, and must therefore cease. Wheel chairs should be checked regularly and serviced periodically to ensure the protection of service users from accident. The use of wheel chairs should also be supported by risk assessment. A policy on caring for the service user who is dying is in place at the home, and arrangements are made for them to remain at College House, in the latter stages of life, whenever possible, with support from community nurses. Bereavement training has been provided for staff, in order to increase their awareness of the issues surrounding death, and to enable them to support the service user and their family. The wishes of service users concerning terminal care and after death arrangements are discussed with them, and their family when appropriate, and a record is maintained in their plan of care. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 15 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. 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. College House is very much part of the local community, and links are maintained which enrich the social lives of service users outside the home. The wishes and preferences of service users are respected, and they are encouraged to make choices about all the activities of daily living, in a way that encourages and promotes independence. Service users have complete freedom in regard to their contacts, both within and outside the home, which enables a good quality of life to be maintained. Service users are offered a choice of nutritious, wholesome and well-balanced meals, and the records provide evidence that a satisfactory diet is taken by everyone. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 16 EVIDENCE: Residents have freedom of choice in regard to their contacts, both within and outside the home, and they are enabled to make choices with regard to all the activities of daily living, for example, when to get up or go to bed, and how to spend their day, or whether to join in the various pastimes. This was confirmed in conversation with service users and staff, and also in comments received from relatives. One relative who visits at least twice each week was very positive about the way her aunt has been cared for, and how much she has improved since being resident at College House. The specific interests of each individual are recorded in their plan of care, and residents meetings are organised every few months, to further encourage their involvement in the running of their home. Various in-house activities are available should residents choose to be involved, and a programme is to be found on the notice board. During conversations with residents, they were telling me about the exercises they had been doing a little earlier, which included ‘figure of eight’ movements with their arms and legs, and how this had caused great amusement as they tied themselves up in knots. One lady, who is nearly 100 years old said she walks into the town quite often, another service user goes out regularly with his family, and one resident attends a local day centre twice a week. Other items recorded in the activities log included the following: Having a quiz, poetry reading, reminiscence, arts and crafts, bingo, card and board games, skittles, knitting, singalong etc. When the weather is warmer, visits to local gardens for morning coffee or afternoon tea are organised, and also reminiscence trips to old haunts. One resident was saying how much she would like to go to the seaside for a day, and expects that arrangements will be made for her to do this. Communion is provided by a local minister every month, and service users are enabled to attend church if this is their wish. There are no specific visiting times and the involvement of family and friends is actively encouraged. Visitors are made very welcome, and all their comments were positive both in person and in their written responses about the care provided to their relatives and friends at the home, and about the kindness of staff. These included the following: College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 17 • • • • • • • • • College House is wonderfully welcoming This is home in the true sense of the word The management are always approachable Every effort is made by staff to include everyone Everyone is looked after very well The staff are always helpful and very caring The house is always clean and fresh There is always something going on I feel very confident about the care The arrangements regarding the provision of food reflect the individual preferences of each service user, and food is always an agenda item at residents meetings. Service users were complimentary about the food, and they said there was plenty of variety and that the meals were nicely cooked. The menus indicated that a set meal was served at lunchtime each day, with an alternative always available. There was a choice of at least two vegetables and potatoes, with the main course. The teatime meal usually consists of a lighter meal, which sometimes includes a cooked option. The meals served on the day of the inspectors visit were nicely presented and appeared to be appetizing and nutritious. A dining room is available for the use of service users, or they may choose to have their meals in their own room if they wish. One service user does not like to have the main meal at lunchtime, therefore agreement has been reached for this to be served at suppertime, and the relevant information is also recorded in the care plan. The inspector spent some time discussing the catering arrangements with the cook, who has recently joined the team at the home. Several changes have already been implemented, and she explained she would be taking on more responsibility for managing the kitchen, and also intended to involve service users to a greater extent. The likes, dislikes and preferences of service users are already known to staff, and are well documented. Special diets can be provided as necessary, but only diabetic diets are needed at present. Appropriate records are being maintained in relation to specimen foods, and fridge/freezer temperatures, and cleaning schedules are also in place. The kitchen, although quite small, is functional, tidy and very clean. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The complaints procedure is implemented at the home in an open and efficient manner. Service users legal rights are protected through the robust policies and procedures that are in place. The policy and procedures relating to abuse, and the training provided for staff, should ensure the protection of the people who live there, and who may be vulnerable. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home operates a satisfactory complaints procedure, which is included in the Service Users Guide and also in the Statement of Purpose, and any issues are dealt with immediately. Service users and their families are encouraged to express their views, and their responses, both verbally and in writing, indicated that they are aware of the procedure. There have been no complaints about the service recorded during the past year, but neither were any compliments included in the log. The acting care manager is encouraged to record all comments made about the home and the care provided, to give a more balanced view of the service. The policies within the home recognise the rights of service users in every respect, and a Charter of Rights that acknowledges equality of opportunity for everyone, that values their differences and promotes the independence of each person, has been produced. Residents are assisted to access medical, legal, advocacy and civic services depending on their individual needs and wishes, and arrangements are made for postal voting where service users are not able to attend the polling station in person. A policy on the Protection of Vulnerable Adults has been produced, and includes guidance from the Department of Health publication “No Secrets,” specifically in relation to whistle blowing. A policy on restraint is also provided. These procedures, together with the training that has been provided for staff, to increase their awareness of the many aspects of abuse, should ensure the safety and protection of service users. Staff were able to confirm to the inspector, their understanding of these matters, during discussions with them at the time of the visit. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained house that is clean and comfortable, attractively decorated and furnished, and in an environment that is safe and secure. The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of service users. The ongoing programme of improvement and upgrading of the home helps to enhance the quality of life for the residents who live there. The safety of service users would be promoted more effectively by ensuring that appropriate equipment is provided and maintained to a satisfactory standard. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 21 EVIDENCE: College House is a large detached house standing in its own grounds, and situated within easy walking distance of the shops and local amenities in Tenbury Wells. Some parts of the house are quite old, but it has been upgraded and adapted to provide a safe, comfortable and warm environment for service users. The building is well maintained, and has been completely redecorated recently. The development of the communal areas of the home have improved facilities for service users, and the lounge in particular is a very pleasant room in which to sit and relax. There is a separate dining room, and the gardens to the front of the house are accessible to service users, and quite spectacular during the summer months. Everyone was delighted that the home achieved 2nd prize in the competition for best garden in the town, and are enthusiastically planning to get the first prize later this year. Several new carpets have been fitted, new chairs have also been provided, and some wardrobes have been replaced in the bedrooms. The curtains are now very bright and attractive, and service users said how lovely the home is and how happy they are to be living here. The bedrooms are tastefully decorated and furnished to a high standard, and reflect the individuality of the service users, who are each encouraged to personalise their rooms. The policy of the home is to only let rooms on a shared basis if this is the wish of both service users, and this agreement is recorded in their care plans. The provision of bathrooms, showers and toilets is adequate, and they are suitably located throughout the home. Consideration is to be given, in the future, to further improving facilities for service users with the provision of en suite facilities in some bedrooms, for which planning permission has been granted. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 22 The new bath seat in a first floor bathroom was discussed with the inspector by some of the service users, and no-one actually likes it, because they cannot be lowered into the water. Discussions with the acting care manager confirmed that she is aware of the situation, which will be reviewed with the owner. The inspector advised that an assessment of the premises and facilities by a suitably qualified person, may assist in the provision of appropriate equipment. A new walk-in bath has been fitted in a ground floor bathroom, which provides service users with an alternative type of bath, where they can be immersed in the water, and enjoy a good soak, if this is what they wish. The concerns expressed to the inspector regarding the footrests having been removed from a wheel chair, and the safety of service users therefore being compromised, were discussed with the acting care manager, who confirmed that the situation would be rectified immediately. In addition arrangements are to be made for the wheelchairs, in use at the home, to be serviced regularly, as there was no evidence that this is being done at present. The laundry has been upgraded recently, and a new washing machine and tumble dryer provided, which is helpful to staff in maintaining adequate health and safety standards in regard to laundry procedures. The home is clean and fresh throughout and staff confirmed that they are familiar with the procedures regarding the control of infection, and that they have also been given training in health and safety matters. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 23 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. 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. Service users are supported by a team of experienced and competent staff. The recruitment and selection procedures need to be implemented more rigorously to ensure the protection of service users. Training opportunities available to all staff ensure that they understand their role, and are able to provide appropriate care and support to service users. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 24 EVIDENCE: The staff rotas indicate that staffing is maintained at a level that is adequate for the needs of service users. There is a minimum of two care staff on duty throughout the waking day, and at night one waking and one sleeping carer, with the care manager on call. The care manager is regularly included on the rota as one of the care staff, and in addition she covers the late shift and also does a ‘sleep in’ duty on one or two occasions each week. Catering and domestic staff and a gardener/handyman are also employed at the home. Discussion with the acting manager confirmed that adequate time is available to deal with management issues at the home in addition to covering caring tasks. An administrator provides assistance with some of the paperwork, and a training officer has responsibility for staff training. Service users and their families confirmed they are happy with the standard of care provided, and related this to the number of staff on duty. One resident commented that the staff are, ‘always there to help when I need them’, and another said, ‘there is usually someone around when I want something’. There have been some staff changes during the last 12 months, although the group is fairly stable, several staff having worked at the home for many years. The members of staff with whom the inspector spoke, confirmed that they enjoy their work, and all were very positive about being employed at the home, and also about the training opportunities they are given. The files of two recently appointed members of staff were inspected, and relevant information was recorded and appropriate documentation was in place, with one exception. The files contained an application form, evidence of Criminal Record Bureau (CRB) checks undertaken prior to employment, proof of identity of the applicant, a health declaration, and a photograph, but there were not always two written references on file. The records indicate that ‘core’ training is provided for staff in fire safety, basic first aid, moving and handling, health and safety, and basic food hygiene. In addition, some staff had attended training sessions on diabetes, aggression and restraint, bereavement, and abuse awareness. Future training plans include, the safe handling of medicines and dementia awareness. In addition three members of staff are hoping to commence NVQ training when funding is secured. A training session was in progress on the day of the inspection, although it was not very well attended. An individual training and development assessment and profile is now in place for each member of staff. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Further development of the quality assurance system will enable the views and opinions of service users to have a greater influence in how the home is run. The policies, procedures, and records maintained at the home help to safeguard the rights of service users. The health, safety and welfare of service users and staff is promoted, and procedures are in place to ensure that they are protected in respect of all safe working practices. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager, Mrs Maggie Hope has resigned after working at the home for many years. Ms Claire VanLooy, who was appointed recently, has been in post for almost two months, and has responsibility for the day to day running of the home. An application for registration is to be submitted to the Commission in the near future. The Quality Assurance Programme has been further developed. Questionnaires are circulated and regular meetings held with service users to obtain their views, but these surveys are still to be audited and the results submitted to the Commission. The insurance arrangements for the home and the business are satisfactory, as evidenced by the certificate. A business and financial plan for the home was not available for inspection, therefore this should be produced and a copy submitted to the Commission. Staff have limited involvement in handling the money of service users. The family or a representative usually deal with any financial matters, for residents who are unable, or who do not wish to manage their own affairs. The Registered Provider acts as appointee for two service users at the home, although the interests of the service users are protected by the procedures that are followed. However, the management are advised to explore the possibility of making alternative arrangements. The accident book was checked, and had been completed appropriately. Notifications under Regulation 37, which requires reports to be sent to the Commission of the death, injury or serious illness of a service user, or other events in the home, are now being submitted when necessary. The Registered Provider visits the home regularly, although a report has not been sent to the Commission for several months. The acting care manager confirmed that arrangements are to be made for this situation to be rectified as soon as possible. Contracts are in place for the regular servicing and maintenance of equipment. The Fire Log indicated that fire protection procedures are followed, and weekly checks of the fire alarm system are undertaken. The Fire Risk Assessment has been completed, and an Emergency Evacuation Contingency plan is in place at the home. A health and safety policy and procedure is in place, and all staff are trained in safe working practices. College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 27 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 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 3 18 3 3 3 3 2 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 X 2 3 College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12 Requirement A safe system for moving and handling service users must be provided, and the use of wheel chairs risk assessed. The foot rests must not be removed. Equipment provided at the care home must be maintained in good working order Two written references must be obtained prior to an offer of employment being made Timescale for action 30/06/07 2 3 OP22 OP29 23 19 30/06/07 30/06/07 College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 10 11 Refer to Standard OP3 OP7 OP9 OP16 OP21 OP22 OP31 OP33 OP34 OP35 OP37 Good Practice Recommendations A more detailed, written assessment must be completed before the admission of any service user The plan of care for each service user should be reviewed at least monthly The guidelines for the administration of PRN (as required) medicines should be reviewed All comments, concerns and compliments made about the service should be recorded Further consideration should be given to the development of the en suite facilities for which planning permission has been granted An assessment of the premises should be undertaken by the Community Occupational Therapist, An application for registration should be submitted to the Commission by the acting care manager without delay The results of quality monitoring surveys should be audited and published and a copy submitted to the Commission A business and financial plan for the establishment should be produced, which is reviewed annually A review of the management of service users finances should be undertaken A report must be made to the Commission on the conduct of the care home in accordance with the requirements of Regulation 26 College House Residential Home DS0000064821.V327390.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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