Inspection on 28/07/05 for College Of St. Barnabas

This inspection was carried out on 28th July 2005.

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

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

Other inspections for this house

College Of St. Barnabas 26/07/06

College Of St. Barnabas 20/12/05

College Of St. Barnabas 14/10/04

College Of St. Barnabas 10/05/04

College Of St. Barnabas 13/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE College of St Barnabas Blackberry Lane Lingfield Surrey RH7 6NJ Lead Inspector Janet Daulton Announced 28 July 2005 10:00 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 of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service College of St Barnabas Address Blackberry Lane Lingfield Surrey RH7 6NJ 01342 870369 01342 870193 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) The Council of the College of St Barnabas Heather Bradley Mockler CRH Care Home 25 Category(ies) of OP Old Age registration, with number of places College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Up to 25 beds may be used for the provision of nursing care. Date Implemented - 1 April 2002 The age/age range of the persons to be accommodated will be: OVER 65 YEARS Date Implemented - 1 April 2002 The designation and numbers of staff should be kept under review in relation to the dependency levels of service users and, in particular, the degree of need for nursing care. Date Implemented 21 January 2004 Date of last inspection 14 October 2004 Brief Description of the Service: The College of St Barnabas is a Charitable Trust providing retirement accomodation in two categories. The categories are sheltered accomodation in cloistered dwellings, and nursing care provision in the main part of the house. Service provision is specifically for members of the Clergy of the Church of England or its sister Churches. Provision is also extended to the spouses of clergy, retired licenced readers, and full time church workers. Other applicants may be accepted as fee paying service users dependent on bed availability. This inspection report relates only to the registered care facilities with nursing provision. A separate report will be issued for the domicilary care provided in the cloisters. The home is situated in extensive grounds near the village of Dormans in Surrey. The home is registered for 25 places, all single rooms with ensuite facilities. There are several communal facilities, including lounges, dining rooms and an extensive library. The College has two chapels, and Eucharist and Evensong are celebrated daily. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was the first inspection carried out by the Commission for Social care Inspection for the year 20052006. The inspection was carried out by Janet Daulton, Lead inspector for the service. The Manager Mrs. H. Mockler, and the Responsible Individual Mr. P. Wilkin were present during the inspection. A tour of the premises took place. Five care plans, the complaints log, staff recruitment files, and a sample of safety certificates were inspected. The inspector spoke to 10 service users, and took lunch in the dining room with the service users. The inspector also spoke with some of the staff on duty at the time of the inspection. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the inspection. What the service does well: The home continues to provide a homely and attractive environment for the service users. The staff were seen to be caring for the service users in a professional and respectful way. Service users said that the staff treated them well. Meals were varied, well balanced and nicely presented, offering a choice and variety. The activity provision was varied and adapted to the interests of the service users. The service users care plans were detailed. They gave clear instructions to the staff about the service users needs and the care that had to be given to meet those needs. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.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 of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,6 Service users have their needs assessed before they move permanently into the home to ensure that the home can provide for those needs EVIDENCE: All prospective service users are admitted for a trial period, during which time the care staff carry out a full assessment of health, physical, mental and social needs to ensure that the home is suitable and can meet the needs that have been identified. The admission policy did not state this, and following discussion with the Manager and Responsible individual the admission policy was amended and implemented on the day of the inspection. There were no service users receiving intermediate care in the home. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 The service users needs were set out in an individual plan with actions stated to meet the needs, There was written evidence that these were being met, and there was a regular review of whether the needs had changed. Medication was administered safely. EVIDENCE: Service users and relatives spoken with were complimentary regarding the care that they received in the home. Each service user had a detailed comprehensive plan of care, which included appropriate risk assessments, and also included the service users social and leisure interests. It was pleasing to note this holistic approach to the care plan. There was evidence of reviewing of care plans, and they were signed by the service users. A recommendation was made that a risk assessment was completed for one service user with specific problems. All service users were registered with a GP, who visited weekly. Service users paid for chiropody visits and access to physiotherapy was usually via a GP referral. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 10 There were adequate pressure relieving devices and moving and handling equipment. Staff were observed to care for the service users in a professional and respectful way. There were satisfactory arrangements to ensure the privacy and dignity of the service users; consultations with health and social care professionals were held in the service users rooms, and service users could have their own private telephone access in their rooms, for which they would pay. Medication was administered and stored in line with the homes policy. Risk assessments were completed on 3 service users who self-administered their medication. The inspector noted that the homely remedy list needs to be signed by the GP, and a recommendation was made. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 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 standard(s) 12,13,14,15 The activity provision met the needs and wishes of the service users. The service users were enabled to maintain their independence as much as possible. Catering arrangements were good, and service users received varied and nutritious food, which was appropriately served. EVIDENCE: The activity provision centred around the chapel, with daily services. Several of the service users took an active part in these activities. Other activities arranged included poetry reading, a church choir, and therapeutic art classes. There was access to all the community activities arranged for the sheltered housing part of the College, and a programme was displayed. Service users were very satisfied with the activity provision, and were free to join in or abstain as they wished. The care staff were not involved in any financial arrangements, and the service users or their representatives handled their own financial affairs. The inspector took lunch with the service users. The meal served on the day of the inspection was well presented and tasty. The service users commented College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 12 that there was always a choice available at meal times, and that they were satisfied with the choices available. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 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 standard(s) 16,18 The home has a complaints procedure, which includes timescales for the process. Service users are protected by the homes policies and training of staff in vulnerable adults procedures EVIDENCE: The home has a complaints procedure, which was displayed, in the home. The homes complaint log was inspected. There were no complaints detailed in this log. Staff have received vulnerable adults training. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 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 standard(s) 19, 26. The location and layout of the home is suitable for its stated purpose. It is accessible and safe with a pleasant and homely atmosphere. EVIDENCE: The inspector toured the home and saw all the communal areas and some of the service users bedrooms. The service users rooms were individualised with the occupants own personal effects and pictures. Several of the bedroom doors did not have a lock fitted. To fully meet the NMS 24 the doors to service users private accommodation must be fitted with locks and service provided with keys unless their risk assessment suggests otherwise. Following discussion during the inspection registered person had submitted a variation for internal works to reduce 3 bedrooms to 2, with a subsequent reduction in registered places. These rooms were seen at inspection. The College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 15 Registered person must confirm in writing that one empty room has all the fixtures and fittings as detailed in the NMS 24 before the variation can be granted. The room must not be occupied until this is completed. The communal areas, although comfortable and well furnished looked tired decoratively, and would benefit from a programme of renewal and decoration. The Responsible Individual for the Charitable Trust informed the inspector that this matter was being addressed by the Trustees. A requirement is made that a programme is produced for routine maintenance and redecoration of the premises. The inspector was informed that one of the lifts was out of order, and required a substantial repair, which was being actioned as soon as the relevant part arrived. The Service users who have to use that lift stated that it was an inconvenience as it necessitated them using the stairs, which they found difficult at times The inspector was informed that there were no service users confined to their room because of the lift breakdown. The registered person must ensure that all service users can safely negotiate the stairs, and risk assessments must be completed where necessary. The registered person must notify the CSCI when the lift has been repaired. All parts of the home were seen to be clean and free from offensive odours. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 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 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) 27,29 30, The numbers of staff on duty during the inspection were sufficient to meet the needs of the service users. The recruitment process was being followed to ensure that only suitable staff were being employed. EVIDENCE: The staffing rota showed that adequate staffing numbers were being maintained. A trained nurse was on duty on all shifts. There had been 1 new employee since the last inspection. The staff file was examined. This contained the necessary checks and references. The induction record was also seen. Service users were generally very complimentary about the staff at the home, stating “nothing was too much trouble.” Staff had received mandatory training in moving and handling and fire safety. All interactions observed between staff and service users during the inspection were seen to be caring and respectful. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 17 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) 31,33,35,38 The home benefited from stable and competent management. The home did not have an effective quality and monitoring system in place that was based on seeking the views of the service users, relatives, and interested parties in the community. Policies, procedures, and practices were in place to ensure, as far as is reasonably practicable, the health, safety, and welfare of the service users. EVIDENCE: The management systems place in the home ensured that there was clear accountability. The Manager and Deputy had been working in the home for several years. The home had an audit tool for obtaining service users views about the care and service provided, however at the time of the inspection this had not yet been implemented, and a requirement was made regarding this. Several service records were examined at inspection and seen to be in order. A fire risk assessment had been completed in June 2005. Accident and incident books were maintained, and the home had designated first aiders. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 18 The inspector considered that the kitchen floor was unsafe as it was very slippery from a spilt substance, and an immediate requirement was made to wash the floor. This was actioned as the inspector left. College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 19 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 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 x 1 x x x x 3 College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 23(2) Requirement Timescale for action September 30 th 2005. With Immedfiate effect. 2. 19 3. 4. 19 24 5. 24 6. 33 A progamme for redecoration and maintenance of the premises must be produced with time scales for implementation 13(4)(a)(c The registered person must ensure that all service users can safely negotiate the stairs until the lift is repaired. Risk assessments must be completed where necessary 23(2) The registered person must inform the CSCI when the lift is repaired 12(4) (a) Dorrs to service users private accommodtaion are fitted with locks, and service users areprovided with keys unless their risk assessment suggests otherwise 16(1) The registered person must inform the CSCI in writing that the empty room has all the furnishings nad fittings as detailed in the NMS, before the variation will be granted. 24(1)(2)( The Registered Person must 3) implement a system of reviewing the care and services providerd by the home, involving the service users, and a report must be produced which is available to H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Without delay when actioned October 31st 2005 Without delay when completed. October 31st 2005 College of St Barnabas Version 1.40 Page 21 the service users. 7. 38 13(4) The kitchen floor must be attended to as very slippery froma spilt substance Immediate. Actioned at time of inspection. 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. Refer to Standard 9 7 Good Practice Recommendations The GP signs the Homely Remedy list. a risk assessment should be completed for a service user with specific difficulties College of St Barnabas H58 H09 s13310 College of St Barnabas 280705 v221994 280705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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