Inspection on 15/02/06 for College House Residential Home

This inspection was carried out on 15th February 2006.

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

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

Other inspections for this house

College House Residential Home 17/09/09

College House Residential Home 03/03/09

College House Residential Home 09/09/08

College House Residential Home 12/02/07

College House Residential Home 06/09/05

Similar services:

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Heathlands

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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 R McGorman Unannounced Inspection 15th February 2006 13:00p 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.V278584.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 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 01256 893700 Oaktree Care Ltd Mrs Margaret Ann Hope 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.V278584.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 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 a comfortable home. 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. The home 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 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. The previous owners, Mr & Mrs Currier, who had run the home for 20 years, retired in July last year, when College House was bought by Oaktree Care Ltd. Mrs Joan Pressdee is now registered as the Responsible Individual. Responsibility for the day to day running of the home will continue to rest with Mrs Margaret Hope, who has been the registered care manager for the past 3 years. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine, unannounced inspection was to follow up any previous requirements and recommendations, and to monitor care provision at the home, in relation to the stated aims and objectives. The inspection took approximately 3 hours, and time was spent in conversation with residents and staff, to ascertain their views on living and working at College House. A tour of the building was undertaken, and discussions held with the new Proprietor, about developments that have taken place recently, and also future proposals for maintaining and upgrading the premises. Care records were seen, and the care provision for service users was discussed. The documentation kept in respect of the maintenance of equipment, and safe working practices, including the fire log book and the accident book, was also checked. What the service does well: College House provides a warm welcome. The atmosphere is homely and relaxed, and the environment is comfortable, safe and well maintained. Involvement with the town of Tenbury Wells is encouraged, and service users who wish, are enabled to access the shops and local facilities. The home provides a neighbourly service to people who live in the vicinity of the home, and a meals on wheels service is also organised. A culture of providing good care has been developed over the years, and is being maintained. The home very obviously revolves around the residents, and the mutual respect and consideration shown by everyone is pleasing to observe. Activities are available, both in-house and in the community, although to a lesser extent during the winter months. Comments regarding the food were all positive. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&4 Relevant information is available to prospective service users, to enable an informed decision to be made about their future care. Ongoing review of the changing needs of service users, ensures that the home is able to provide appropriate care. EVIDENCE: A statement of purpose and service users guide is provided to each resident, on admission to the home, together with a Statement of the Terms and Conditions of Residence. The documentation produced in the home has been reviewed to reflect the change of ownership. A review of all service users has been undertaken, to ensure that the home can effectively meet identified needs. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 & 11 The individual plan of care for each resident is well maintained and contains relevant information, to enable the health and personal care needs of service to be met appropriately. Arrangements for the safe administration of medication are in place, although recording procedures are to be reviewed. Training is to be provided for staff to ensure a greater understanding of the issues regarding death and bereavement. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 10 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. Risk assessments are also completed. Service users confirmed they are involved throughout the process, which includes on-going assessment and monthly reviews, unless needed more frequently. The record is then signed by the service user, their key worker, and the care manager. There had been some concerns noted previously regarding the service received from the local pharmacy, therefore following a review, the home has changed to a Monitored Dosage System (MDS) for the administration of medication. Training has been given to staff, and a new drugs trolley provided. The Medication Administration Records (MAR) charts had generally been completed to a satisfactory standard, although some omissions were evident. The home has a policy on caring for the service user who is dying, and arrangements are made for them to remain at College House, in the latter stages of life, whenever possible, with support from community nurses. The involvement of family and friends is actively encouraged. Bereavement training is being arranged for staff, through the Cruse Organisation. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 14 College House is very much part of the local community, and links are maintained which enrich their social life outside the home. The chosen lifestyle of service users meets their cultural and religious interests, provides appropriate leisure opportunities, and matches their expectations. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 12 EVIDENCE: Service users are able to exercise choice about when to get up or go to bed, and how to spend their day. The specific interests of each individual are recorded in their plan of care, and residents meetings are now organised every two months, to further encourage their involvement in the running of their home. A recent change has been made to make the lounge a more peaceful environment, by removing the television, which tended to be on for most of the time, and was not really watched by many people. Service users have a TV in their own room, if they wish to follow anything of interest. The arrangement is of benefit to people with a dementia, who can become quite agitated by ‘the box’, but is to be reviewed in the near future, to ensure the new arrangements suit all concerned. Various in-house activities are available should residents choose to be involved, and a programme is to be found on the notice board. A reminiscence workbook has been purchased to enable staff to follow a programme, and work more effectively with service users. Regular visits to local gardens for morning coffee or afternoon tea are organised, and also reminiscence trips to old haunts, weather permitting. Communion is provided by a local minister, and service users are enabled to attend church if this is their wish. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a satisfactory complaints procedure, and service users confirmed that their views are responded to appropriately. Further training on abuse is to be provided for staff to ensure their full understanding of all the issues. EVIDENCE: The home operates an appropriate complaints procedure, which is included in the service users guide and the homes statement of purpose, although responses from some service users indicated that they were not aware of the procedure. A record is maintained of any complaints made, although none have been received recently. Compliments are also recorded. 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. Further training is to be arranged for all staff at the home, to ensure their understanding of the many forms of abuse. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23,25 & 26 The standard of cleanliness is excellent, the décor and furnishings are in good condition and the building is well maintained throughout, providing a very comfortable and homely environment for residents. The needs of residents are met in relation to the environment in which they live, and their safety and wellbeing is assured as far as possible at College House. The good communal facilities and the provision of appropriate equipment, helps to maximise independence and enhance the quality of life for residents living at the home. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 15 EVIDENCE: College House provides comfortable and homely accommodation on both the ground and first floors of the building, which is well maintained, nicely decorated and furnished to a good standard. A record of the maintenance programme should be maintained. There are 5 bedrooms large enough for shared use, although only 2 are registered for double occupancy. The policy of the home is to only let rooms on a shared basis if this is the wish of both service users. Bedrooms are personalised by service users, and the provision of furniture and fittings complies with National Minimum Standards. The provision of bathrooms/showers and toilets is adequate, and they are suitably located throughout the home, but further consideration is to be given to the provision of en suite facilities in some bedrooms, for which planning permission has been granted. All rooms are centrally heated, radiators are guarded, and regulators fitted to enable service users to control the heating levels in their bedrooms. The rooms are naturally ventilated and restrictors are fitted to all windows. Emergency lighting is provided throughout the house and records indicate that this is regularly checked. The home has not received a recent visit from the Fire safety Officer, although the building, and the fire protection procedures have previously been compliant with requirements. A new Fire Risk Assessment is being developed, and the Emergency Evacuation Contingency plan is being reviewed. The home is anticipating an imminent visit from the Environmental Health Officer. Infection control polices have been produced, including the safe handling and disposal of clinical waste. The home is clean and odour free. Documentation in respect of the servicing and maintenance of equipment at the home is completed to a satisfactory standard, and procedures have been reviewed recently. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 30 The home is adequately staffed with employees who are experienced and competent to care for older people. Training opportunities are provided for all staff, and a clear understanding of their roles and responsibilities is demonstrated, although the need for further training is identified. EVIDENCE: The rotas indicate a minimum of two carers on duty through the waking day with an additional carer on duty during the busier times. In addition, catering and domestic staff, and a gardener/handyman are also employed. These staffing levels are considered by the management of the home to be adequate, and have been maintained consistently for many years. They can be varied depending on the needs of service users, but two residents indicated, in their responses, that they feel there are not always enough staff on duty. Training is considered to be important at College House, and the majority of staff have done the basic ‘core’ training. Care related training is also provided, and several staff have completed the NVQ Level 2 in Care. An individual training and development assessment and profile remains outstanding. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 17 College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,37 & 38 The Registered Manager is experienced, and qualified both in management and care, and residents and staff benefit from the positive approach and leadership they receive. 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, comply with legislative requirements, and therefore help to safeguard the rights of service users. The health, safety and welfare of residents and staff is promoted at the home, and procedures are in place to ensure that they are protected in respect of all safe working practices. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 19 EVIDENCE: The registered manager, Mrs Maggie Hope has many years experience in caring for older people. She is an NVQ Assessor and has achieved the City and Guilds Registered Manager’s Award in Management and Care. A Quality Assurance Programme has been introduced at the home, and is to be developed further to reflect the new management. 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 Proprietor verbally confirmed the financial viability of the business. Appropriate insurance cover is provided, to the relevant level, as evidenced by the certificate displayed at the home. Staff have minimal involvement with service users finances. The family or a representative, of the majority of service users deal with any financial matters, although the manager is appointee for two service users. The records seen are being maintained to a satisfactory standard, although the management are advised to make alternative arrangements if possible. Safe storage of valuables is available. The accident book was checked, and had been completed to a satisfactory standard, although the management had failed to inform the Commission of one Regulation 37 notification. Regulation 26 notifications have been submitted to the Commission as required. Contracts are in place for the regular servicing and maintenance of equipment. The Fire Log indicated that weekly checks of the fire alarm system are undertaken with the required frequency, and a practice evacuation had been undertaken recently, with a very positive result. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 20 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X 3 X 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 X X 2 College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation 13 Requirement The Medication Administration Records must be completed fully and accurately, and signed by staff. Training must be provided for all staff in regard to the Protection of Vulnerable Adults An individual training and development assessment and profile must be provided for staff The results of quality monitoring surveys should be audited, published and a copy submitted to the Commission Notification must be made to the Commission of the occurrence of all accidents, injuries, illness and incidents, in accordance with Regulation 37 and Standard 38. Timescale for action 28/02/06 2 3 4 OP18 OP30 OP33 18 18 24 31/03/06 31/03/06 31/03/06 5 OP38 37 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 22 No. 1 2 3 4 5 6 7 Refer to Standard OP11 OP16 OP19 OP19 OP21 OP27 OP34 Good Practice Recommendations Training should be provided for all staff on dealing with death and bereavement The management should ensure that each person living at the home is made aware of, and fully understands procedure for making a complaint A programme of routine maintenance of the home should be submitted to the Commission The Fire Risk Assessment for the home should be further developed, and an emergency evacuation contingency plan produced The planning permission for development of en suite facilities in the bedrooms should be reviewed and proposals for this work submitted to the Commission Staffing levels should be kept under review to ensure that there are adequate numbers of staff to provide for the identified needs of service users A review of the management of service users finances should be undertaken College House Residential Home DS0000064821.V278584.R01.S.doc Version 5.1 Page 23 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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