Inspection on 06/09/05 for College House Residential Home

This inspection was carried out on 6th September 2005.

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 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 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 15/02/06

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Maple Lodge

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 Berrington Road Tenbury Wells Worcestershire WR15 8EJ Lead Inspector Rachel McGorman Unannounced 6 September 2005 - 10:00 a.m. The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service College House Address Berrington Road Tenbury Wells Worcestershire WR15 8EJ 01526 893700 -1562 893700 oaktreecare@btconnect.com Oaktree Care Ltd. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Margaret Ann Hope CRH 12 Dementia - over 65 Old age Physical disability - over 65 12 12 12 Category(ies) of DE(E) registration, with number OP of places PD(E) College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration other than those referred to on the previous page Date of last inspection 22 February 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 home has been owned and run by Mr & Mrs Currier for 20 years, until their retirement in July of this year, when College House was bought by Oaktree Care Ltd. Mrs Joan Pressdee is 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 E52 S64821 College House V245377 060905.doc Version 1.40 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 4 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 and the care manager, about future proposals for development and upgrading of the premises. Care records were seen, and the care provision for service users was discussed in detail. 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, and the atmosphere is homely and relaxed. The environment is comfortable, safe and well maintained. The close proximity of the home to the centre of Tenbury Wells enables easy access to the shops, and encourages involvement with the local community. 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. Staff are enthusiastic about their work, and ‘a culture of providing good care’, has been developed over the years. The home very obviously revolves around the residents, and the mutual respect and consideration shown by everyone was pleasing to observe. The activities available are many and varied, both inhouse and in the community, and regular outings are organised. Comments regarding the food were all positive. The new management of the home, which has been in place for just over one month are to be commended for the minimal disruption that has been caused. The transition has been so smooth that hardly anyone noticed that a new company was now in place. The new Proprietor confirmed that any future changes will be subject to consultation. College House E52 S64821 College House V245377 060905.doc Version 1.40 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 E52 S64821 College House V245377 060905.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 & 5 Relevant information is available to prospective service users, to enable an informed decision to be made about their future care. A detailed assessment is undertaken by the manager to ensure that the home is able to meet the identified needs of a prospective resident. An established admission procedure ensures that the introduction to residential care is handled sensitively by staff. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 9 EVIDENCE: The statement of purpose and service users guide is provided to each resident, together with the Charter of Rights and the Complaints Procedure for the home. A Statement of the Terms and Conditions of Residence is given to each resident on admission to the home. The documents each contain relevant information, and the signatures of all parties to the agreement are obtained. College House has a well-established admissions procedure, which includes a visit to the home, with an opportunity to have a meal and possibly an overnight stay. A period of respite care can also be arranged, and some service users attend for day care, prior to making a decision about their future care needs. A comprehensive assessment is undertaken prior to admission, which forms the basis of the plan of care for the service user and covers all aspects of their care needs. The documentation currently in place regarding College House is satisfactory. A new draft statement of purpose and service users guide has been produced by Oaktree Care Ltd. The new Proprietor has expressed her intention to review all the documentation to reflect the change in ownership at the earliest opportunity. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 & 10 The individual plan of care for each resident is maintained to a satisfactory standard and contains relevant information, which ensures that the health and personal care needs of service users are met appropriately. Arrangements for the safe administration of medication were in place. The privacy and dignity of each individual is respected, and the atmosphere throughout the home is one of mutual esteem and regard. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 11 EVIDENCE: The Training Masters System of care planning is to continue to be used by staff at College House. The health, social and personal needs of service users are covered, and their care plans are completed to a very satisfactory standard. Risk assessments are included. Service users confirmed they are involved throughout the process, which includes on-going assessment and monthly reviews, unless these are needed more frequently. The record is signed by the service user, their key worker, and the care manager. The advice and support of the primary care team is sought and specialist equipment obtained when appropriate e.g. mattress/cushions. Access to all health care services is made available to service users. The Medication Administration Records are completed to a satisfactory standard, and appropriate procedures relating to the administration of medication in the home have been implemented. A clear and comprehensive medication policy is in place. Appropriate arrangements are made for service users who wish to selfmedicate, and a risk assessment is undertaken. Some concerns were noted regarding the service received from the local pharmacy, and consideration is being given to introducing a more effective system for the home. The dignity and respect given by staff to everyone living at the home was pleasing to observe, and was confirmed in conversation with residents. Comments were consistently positive from each service user regarding all aspects of their care. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 & 15. College House is very much part of the local community, and links are maintained which enrich their social life outside the home The lifestyle of service users meets their cultural and religious interests, provides appropriate leisure opportunities, and matches their expectations. Nutritious and wholesome food was provided for residents, with seasonal variations, and individual wishes and needs were catered for. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 13 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. The involvement of family and friends is actively encouraged and they are able to have a meal at the home by prior arrangement. Various in-house activities are available should residents choose to be involved, and a programme is to be found on the notice board. Regular outings are arranged and have recently included a river trip on the Severn from Worcester, which is still being talked about with great excitement. Regular visits to the local Burford House gardens for morning coffee or afternoon tea are organised, and also reminiscence trips to old haunts. Communion is provided by a local minister, and service users are enabled to attend church if this is their wish. Service users all expressed satisfaction with the standard of the food, and confirmed that they are consulted about their preferences. A four weekly menu is produced at the home, is varied and provides a balanced diet. Special requirements can be catered for, and assistance is given with eating whenever necessary. Recent changes in relation to suppliers has improved the quality and the cost effectiveness regarding food purchases, was the opinion of the management. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has a satisfactory complaints procedure, and service users confirmed that their views are responded to appropriately. The awareness by staff of the issues relating to abuse, and the protection of vulnerable adults, has resulted in the development of an open culture within the home. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 15 EVIDENCE: The home operates an appropriate complaints procedure, which is included in the service users guide and the homes statement of purpose. A record is maintained of any complaints made, although none have been received recently. Service users are made aware of the procedure and they confirmed that any concerns expressed are responded to immediately. Compliments are also recorded and included the following comments: • • The fact that mother is so attentively cared for means a great deal to us The care provided is over and above the expected standard 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 included. The guidance published by Worcestershire County Council is followed. A document that details the many forms of abuse has been introduced and discussions held with staff to enable a greater understanding of the issues. Further training is to be arranged. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,24 & 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, as recommended by a qualified occupational therapist, helps to maximise independence and enhance the quality of life for residents living at the home. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 17 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. There is a pleasant garden to the front of the house, which is accessible to service users. The home entered the ‘Tenbury in Bloom’ competition and gained 3rd place, which everyone considered to be a great achievement. There are separate sitting and dining arrangements in the main house, plus further communal areas within the bungalow, for the two service users living there. Individual space requirements are met at College House. 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. There are 4 showers and 1 bath, all with toilets, suitably located throughout the home. In addition two bedrooms have en-suite toilet facilities. Consideration is being given to the provision of en suite facilities in some bedrooms, for which planning permission has been granted. An assessment of the house has been undertaken previously by an occupational therapist. A passenger lift provides access to all parts of the home and assisted bathing and toilet facilities are available. The call bell system fitted throughout the home is portable and service users are enabled to access all areas in close proximity to the home, and to summon assistance when necessary. Infection control polices have been produced including the safe handling and disposal of clinical waste. The home is clean and odour free. There are no outstanding requirements following a recent visit from the Environmental Health Officer. Documentation in respect of the servicing and maintenance of the equipment at the home is completed to a satisfactory standard. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 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, who demonstrate a clear understanding of their roles and responsibilities. The morale of staff is good, and they benefit from being part of a cohesive team, which enables them to consistently provide a good standard of care. Recruitment and selection procedures are detailed and thorough, and help to ensure the protection of residents. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 19 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. A training programme is in place at the home and the Training Masters System is used to record the training and development of each member of staff. Training is considered to be important and the majority of staff have done basic ‘core’ training. Sessions have been provided on Basic Food Hygiene, Moving and Handling, Fire Awareness, and Health and Safety in the Workplace. In addition further care related training is provided and includes podiatry, medication administration, death and dying catheter care and infection control. The Induction and Foundation training to the National Training Organisation specification is being followed, although this is being replaced with Skills for Life training. Some staff attend Ludlow College, while some courses are accessed through the ‘Distance Learning Programme’. The National Vocational Qualification training is also provided for staff working at the home. 5 staff have achieved the NVQ Level 2 in Care and 3 staff are currently working towards the qualification. 2 staff have obtained Level 3 and the Care manager has Level 4 care. The recruitment and selection procedures at the home are thorough, and follow the Legal Personal and Management Services format. There have been some changes within the staff group during the last 12 months, although the staffing situation at the home is usually quite stable. The records indicate that appropriate procedures are followed in respect of staff employment. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 & 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. Supervision procedures provide relevant support to staff, and help to create an increased awareness of their roles and responsibilities. Effective quality monitoring systems are in place, and encourage the views of all interested parties on the way in which the home is run. 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 E52 S64821 College House V245377 060905.doc Version 1.40 Page 21 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. The leadership and management style at the home was observed as being open and positive, and a very professional approach was maintained by all concerned. 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 to be audited and the results submitted to the Commission. A formal programme for the supervision and appraisal of care staff has been introduced, and is considered by staff and management to be mutually beneficial. A satisfactory Health and Safety Policy is in place, and copies of Health and Safety legislation are available in the home. Training is provided in all aspects of health and safety and procedures are implemented to ensure the maintenance of a safe environment. Regular weekly tests are undertaken and the fire alarms tested, with appropriate records maintained. The records are maintained to a satisfactory standard at the home. The accident book was seen, and an incident involving a service user who became physically aggressive towards a member of staff was noted, but had not been reported to the Commission under Regulation 37. The situation had otherwise been managed appropriately. Regulation 26 notifications have been submitted to the Commission as required. College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 2 3 College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 23 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 38 Regulation 37 Requirement 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 Immediate & ongoing 2. 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. Refer to Standard 1 18 30 33 Good Practice Recommendations Information provided for service users should reflect the change of ownership of the home Training should be provided for staff relating to the Protection of Vulnerable Adults A staff training and development programme should be introduced at the home The results of quality monitoring surveys should be audited, published and a copy submitted to the Commission College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 24 Commission for Social Care Inspection The Coach House John Comyn Drive 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. Extracts may not be used or reproduced without the express permission of CSCI College House E52 S64821 College House V245377 060905.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!