Inspection on 17/02/06 for Collingwood

This inspection was carried out on 17th February 2006.

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

Collingwood 07/06/07

Collingwood 24/10/06

Collingwood 05/11/05

Collingwood 15/09/04

Collingwood 28/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Collingwood 78a Bath Road Longwell Green South Glos BS30 9DG Lead Inspector Chris Lewis Announced Inspection 17th February 2006 09:30 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 Collingwood DS0000003320.V277714.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. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Collingwood Address 78a Bath Road Longwell Green South Glos BS30 9DG 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) 0117 9324527 NONE Mrs Frances Stephanie Bailey Mrs Wendy Ann Pullin Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 21 persons aged 65 years and over requiring personal care only 5th November 2005 Date of last inspection Brief Description of the Service: Collingwood is a privately owned care home registered to provide accommodation and personal care for up to 21 older people. The home is situated in a cul-de-sac in the residential area of Longwell Green. It is within walking distance of nearby shops and other amenities including medical services. The area is well served by public transport. There is easy access to Bristol and Bath. The M4 and M5 motorways are within easy reach. The property is stone built on two levels with an additional extension to the side. There is a passenger lift. There are attractive, well maintained gardens which are fully accessible to the residents. Accommodation is provided on two floors comprising of 21 single rooms. All rooms have en suite toilet facilities and wash hand basins. There are two lounges and a dining room on the ground floor. Assisted bathrooms and toilet facilities are situated on both floors. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an announced inspection carried out by Christopher Lewis to Collingwood over a period of seven hours. He was given unrestricted access to all parts of the Home during the visit and he was able to meet with a significant proportion of the Home’s residents. He also spoke with a number of the residents’ relatives. He also interviewed both Mrs Wendy Pullin, the Home’s registered manager and members of her staff. In addition, he met the Home’s proprietor. Staff were also observed going about their duties. The majority of residents’ bedrooms were seen, as well as the gardens and other communal areas. Care records were examined along with such things as menus and the Home’s policies and procedures. A lunch-time meal was taken in the company of the residents. What the service does well: What has improved since the last inspection? This inspection was conducted only a few months after the last; the Manager has either tackled the issues that came up then or at least begun to address them. The issues include: more detailed care plans, fully recording any complaint made by residents, ensuring that all staff are CRB and POVA checked, meeting the various training requirements made, formalising staff supervision and conducting a specific home fire risk assessment. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 6 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. Collingwood DS0000003320.V277714.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 Collingwood DS0000003320.V277714.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, 2, 3, 4 and 5. The Home’s Statement of Purpose and User’s Guide is comprehensive and well laid out. Contracts are in place and residents needs are assessed before they move in. Prospective residents are able to visit the Home before deciding whether they want to stay. EVIDENCE: Collingwood’s Statement of Purpose and a copy of the Service User’s Guide was seen. Both give an excellent overview of what the Home can offer its residents. Relevant information about Mrs Pullin, the Registered Manager and care staff is included. The statement of terms and conditions were examined from a representative sample of four of the residents’ files and they had all been signed by the residents and a representative of the Home. By tracking cases through from enquiries onwards, it was evident that a detailed admission assessment had been carried out with each of these four residents. The assessments examined care needs (such as health, mobility, Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 9 mental health and personal care issues) and consideration had been given to how best those needs could be met. One of the residents’ files examined needed to have a clear date of the next review added. The Home is in the process of adopting a new, more ‘user-friendly’ care plan approach which would appear to be successful. The residents were very positive in their comments about life at Collingwood. Examples of what was said include: “I’ve got all my comforts here” and “We’re all very well looked after”. People were particularly positive about Mrs Pullin; one resident said “she is more like a member of my family than a Manager”. Care staff were observed throughout the day of the visit to be treating residents in a respectful and sympathetic manner and generally carrying out their duties in a discrete and unobtrusive way. The Home’s Statement of Purpose describes how prospective residents are encouraged to make a trial visit to the Home. This description was backed up by the Home’s Manager who also stated that relatives are welcome to stay with anyone trying out the Home to see if it suits everyone’s needs and expectations. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 and 11. Individual care plans are completed and the Home ensures that each person is able to access necessary health care services. Care plans are improving and are addressing assessed needs in more detail. It has been agreed that medication practices will be reviewed in conjunction with the Commission for Social Care Inspection. Residents are respectfully treated and their privacy maintained. EVIDENCE: As stated before, following comments made at the last inspection in November, the Manager is in the process of introducing a new format for care plans. A system of key workers monthly checklists is also now in place to keep track of any changes; this is designed to feed into any subsequent alterations to care plans. While this is a laudable approach, it is to be hoped that the new administrative procedure is adhered to by all staff to ensure success of the system. Conversations with the Manager and with residents, coupled with a review of records proved that the health care needs of residents are properly assessed Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 11 and fully met. Wherever possible, residents are able to choose their own GP’s and Mrs Pullin commented on how local doctors are very supportive towards the Home. During the inspection, a doctor made a visit to attend to a resident and his call was dealt with by staff in a relaxed but professional manner. The Home also has good support from the local team of community nurses. The procedures for the administration of medicines were examined but not in any great detail as it was agreed at the last inspection that the pharmacist from the Commission for Social Care Inspection would be asked to visit to offer professional advice. This visit is still awaited by Collingwood and the matter will be followed up. It was noted that medication continues to be administered using the ‘blister pack’ method and the medication administration charts appeared to now be in order with all medication given signed off. Residents are able to ‘self administer’ medication if they so wish. No residents are in need of pressure area care at the present time. Care staff during the visit were seen to speak to residents in a friendly and warm manner and they were also observed knocking on doors before entering residents’ bedrooms. The overall atmosphere of the Home was one of cheerfulness and one resident commented on how easy it had been for her to make new friends at Collingwood. Visitors were seen to come and go as they pleased. The Home has a policy in place which outlines the actions staff should take should a resident die in the Home. This procedure takes account of people’s cultural and religious preferences. Although the Home does not provide nursing care, everything is done to allow a resident to remain in the Home for as long as possible. Local nursing services are again very helpful in such situations. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15. Residents have the opportunity to exercise choice in how they live their lives. Meaningful social activities are provided by the Home. Food provided is of a high standard and continuing contact with those who are important to residents is encouraged. EVIDENCE: Residents confirmed that they are able to get up and go to bed at whatever time they choose, with one group clearly being people who liked to stay up and watch late-night television together when others had turned in. Evidence of social activities was seen including regular bingo, movement for the elderly sessions, visiting entertainers and local church groups. Trips out are organised during the summer months. The proprietor has started teaching French to some of the residents as a form of further stimulation and interest. One such class was taking place during the visit and several residents were to be seen obviously enjoying the experience. Monthly communion services are also held in the Home. There are no major restrictions on when residents may receive visitors other than people being asked to avoid mealtimes. Three people had visitors during the inspection and these visitors were seen to come and go as they wished and to be greeted warmly by staff. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 13 Menus were examined and the preparation of the lunchtime meal was observed. The food is of a good quality and nutritionally balanced. Lunch was taken with the residents and several were heard to comment that the food was good. Staff were seen to be serving in a relaxed, unhurried and patient manner. It was noted that alternatives to the menu were available if someone did not care for what was on offer. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 the following standard(s): 16, 17 and 18. Residents feel able to express any concerns they have openly with the Manager or through the complaints procedure. Residents’ legal rights are protected and they are protected from abuse. EVIDENCE: The resident’s guide gives detailed information on how a resident may make a complaint if they so wished. Information about the complaints procedure was also prominently displayed on notice boards in the Home. The complaints log showed that no grievances had been recorded since the last inspection and that the issue which was highlighted on that occasion has now been properly noted and acted upon by the Manager. Residents spoken with said they felt able to comment to staff if they needed to and no complaints were voiced during the inspection. One resident said, “whatever anyone would find to complain about I do not know”. The opportunity to make constructive suggestions as well (rather than complaints) exists through the use of a locked suggestion box. Overall, the Home appears to have the sort of open culture which would enable residents, staff and relatives to feel confident in making their voices heard if they felt if necessary. Mrs Pullin confirmed that residents had been able to vote at elections (by postal ballot) should they wish to do so. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 15 The Home has a Protection of Vulnerable Adults and a whistle-blowing policy in place and a copy of the Department of Health guidance document “No Secrets” is available to staff. Staff have been trained in POVA issues. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Collingwood is well kept and maintained, clean and tidy throughout. Equipment is provided to maintain independence. Bedrooms and communal areas are well furnished and the garden landscaped and inviting. The Home is generally safe and comfortable to live in although water temperatures need to be monitored and guards fitted to radiators. EVIDENCE: Collingwood is a two-storey property with an extension on the side. The Home is very well maintained with good quality furnishings and fittings throughout. A lift provides access to the upper floor. The gardens are very well looked after and several residents mentioned that they were looking forward to the summer months and tea under the trees. Two large communal areas are available for residents within the Home coupled with a smaller lounge. Collingwood overall has a very homely feel to it. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 17 The majority of the bedrooms were seen; all now have en-suite toilets and hand basins. Bedrooms are light, bright and tidy and personalised with pictures, photographs and personal possessions. Residents are able to bring in small items of furniture into the Home if they wish. All bedrooms contain a television and telephone access point. Three bathrooms are available, all adapted for residents use. All the bathrooms and toilets are kept very clean; one resident confirmed that in her opinion the Home was “spotless”. Call alarms are fitted in all bedrooms and handrails are provided along corridors and lifting aids are available in bathrooms and toilets. Grab rails and seat aids are also in place in the toilets. All rooms are centrally heated; it was noted that radiators have not yet been fitted with guards despite previous assurances that they would be. It will now be required that this work is carried out. Water temperatures were tested at two sinks and the water appeared to be very hot. When measured the temperature was some way over the 43°C required. Hot water will need to be regularly checked to ensure that thermostatic controls are properly set and working in future. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 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, 28, 29 and 30. Adequate numbers of staff are on duty at any one time. Necessary checks on staff, the lack of which was of concern in the past, are now completed. A training action plan for staff is now in place. EVIDENCE: Collingwood’s duty rotas were viewed and the numbers of staff available at any one time is satisfactory. Several of the staff have each been working at the Home for a considerable period of time, thus contributing towards a strong team approach. Comments made by residents and relatives about the staff included “friendly and compassionate” and “it is very much a family atmosphere”. The Manager stated that over 50 of staff have completed or are working towards NVQ Level 2 in Care. Mrs Pullin herself has achieved the Registered Managers Award in July 2005. All staff have or are receiving training in the Protection of Vulnerable Adults. As required at the last inspection, the Home has now completed all CRB and POVA checks and it was emphasised once again the importance of not letting such checks drift in future. Two references were seen on each of the three staff files selected for examination. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 19 The Home is starting to put in place an action plan with induction and other training and Mrs Pullin gave assurances that such training is considered by her to be a priority. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 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, 32, 33, 36, 37 and 38. The Manager, Mrs Pullin is an approachable, experienced and caring manager who appears willing to listen to any suggestions as to how systems may be improved. A quality assurance system needs to be put in place. Health and Safety systems in the Home are generally satisfactory, with some concerns over fire drills. Formal supervision procedures are being adopted. EVIDENCE: Mrs Pullin has worked at Collingwood for around 18 years. As stated before, she has gained the Registered Manager’s Award; she has also NVQ level 4 in care and is a qualified NVQ assessor. Comments made about Mrs Pullin were very positive and included “she runs a good ship” and “she has been wonderful to me”. During the inspection, residents and their relatives were seen to approach Mrs Pullin in a relaxed and friendly way and staff confirmed that she has a very open managerial style. Staff further confirmed that staff meetings were held at the Home and that one was due soon. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 21 The Home has to create an effective quality assurance scheme based on seeking the views of residents in a formal way to ensure that the Home is run in their best interests. The Manager stated that such systems are under consideration with a questionnaire for residents being created; the introduction of a quality assurance programme must now be prioritised. Copies of the required insurance certificates were displayed in the Home. Mrs Pullin stated that the Home does not support residents with their financial affairs at present. A safe is available to store resident’s cash and valuables if required. Mrs Pullin has taken on board the comments on formal supervision mentioned on previous inspections. It was emphasised again to Mrs Pullin that, while accepting that informal supervision of staff takes place frequently on a day-today basis, this is no real substitute for formal one-to-one sessions. The Home has created an excellent set of guidelines for staff supervision; if these are adhered to all should go well in future. Notes of supervision sessions were seen – these must be signed off by both the manager and the member of staff being supervised in future. The records that were examined were well maintained, generally in good order and held securely in the main office. Fire log records showed that weekly tests of fire equipment have taken place and that these tests have been accurately recorded. A specific fire risk assessment for the Home as required previously has now been completed. It was noted that fire drills have not been taking place within the prescribed intervals; then drills must be conducted on time in future. Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 3 3 2 Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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 2 3 4 Standard OP25 OP25 OP33 OP38 Regulation 13 (4)(c) 13 (4)(a) 24 23 (4)(c) Requirement Water temperatures must be maintained close to 43°C. Radiators must be protected by guards. A quality assurance scheme must be put in place. Fire drills must be conducted within prescribed times. Timescale for action 17/02/06 30/04/06 30/06/06 17/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Collingwood DS0000003320.V277714.R01.S.doc Version 5.1 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. 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