Inspection on 24/10/06 for Collingwood

This inspection was carried out on 24th October 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 17/02/06

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 Jon Clarke Key Unannounced Inspection 24th October 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.V317941.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 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.V317941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 21 persons aged 65 years and over requiring personal care only 17th February 2006 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.V317941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over one day, the manager was present during this inspection. As part of this inspection a number of documents were looked at including care plans, training, staffing arrangements and medication administering. There was also an opportunity to discuss with residents and staff their experience of living and working in the home. What the service does well: What has improved since the last inspection? A number of requirements were made at the previous inspection about the health and safety practice of the home. These have been met resulting in a safer environment through the fitting of radiator guards where individuals are at particular risk of falls. This is an area, which the home needs to continue monitoring. The home has also addressed an identified failure to make sure water temperature is accurately controlled so that as far as possible injury to residents is prevented. Records examined evidenced improved practice in undertaking fire drills. The home has also now introduced a Quality Assurance questionnaire: this was discussed with the manager at the time of this inspection and following some Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 6 changes will provide greater opportunity for residents to formally comment on the quality of the service they receive and make suggestions about improvements which could be made. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 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.V317941.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s practice makes sure that an assessment is undertaken for all admissions to the home so that an informed decision can be made about the ability of the home to meet identified health and social care needs. EVIDENCE: A number of pre-admission assessments were seen showing the needs of potential residents about personal care, mobility, health and social circumstances. Where the local authority supports individuals a copy of their assessment and care plan are obtained by the home. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning practice of the home has been improved providing greater information about the care needs of the individuals. However there remain areas for further improvement to make sure staff are fully provided with information so that they can provide the necessary care in a safe and efficient way. There are good arrangements in the home so that health needs are met and residents are protected by the home’s medication policies and procedure. The practices of staff help to make sure that residents are treated with respect and their rights are upheld and protected. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 10 EVIDENCE: A number of care plans were looked at and they generally were well detailed with sections on health, mobility, mental state, and personal care identifing the task and support residents needed. There was a lack of personal information in the form of Personal Profile giving personal history, occupation, and interests. There was also no clear recording of the individual’s wishes on their death though next of kin was recorded. Risk assessments had been completed where individuals were at risk of falls and in one instance where an individual has epileptic seizures though this did not say what actions to take in the event the individual had a seizure. Regular reviews take place and the home use a scoring system to identify risk of skin breakdown, the home had referred an individual to a community nurse where this had identified risk of pressure sores and the home had requested the necessary equipment to alleviate risk. No moving and handling assessment had been completed. Health arrangements are good making sure that residents receive health services such as chiropody, dental and optician. The home also involves the community nurse where residents may need support of a nursing nature. Medication arrangements had previously been the subject of an inspection by the CSCI pharmacist who had identified a number of areas which needed addressing. In looking at administering records, storage and practice there was evidence that staff complete records as required and in addition have completed the required training. Storage arrangements are good though there remains no separate secure controlled drug storage. This will need to be put in place in the event any resident is prescribed a controlled drug. The home’s policy is that where individuals are able they can take responsibility for their medication and currently there are individuals who do so. Risk assessments have been completed to make sure that this remains as safe as possible for the individual. In talking with residents they confirmed that they felt staff treated them “as I would like” when asked about whether this was with respect residents said “always” “I can’t fault how we are treated by all the staff”. Staff were observed speaking with and assisting residents in a sensitive and respectful way. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: Residents confirmed that there are good opportunities for social activities: these include bingo, visiting entertainers and particularly in the summer months outings. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 12 The home has good links with a local church with residents attending events in the church as well as a monthly service taking place in the home. In talking with residents they said “there’s enough for me to do”. They spoke of the “lack of routines” in that they always felt able to choose “how I spend my time”. Residents confirmed that they were able to get up and go to bed when they wished and in looking at records there was evidence of this acceptance by staff of the resident’s right to exercise choice in their daily routines. The home recognises the importance of residents maintaining friendships and contact with relatives. One resident said “the staff are always friendly and when I have visitors always welcome them”. This was also observed during the inspection with staff being approachable and greeting visitors in a warm and welcoming way. The inspector sat with residents whilst they were having lunch and the meal was well presented. There was a relaxed and unhurried atmosphere with staff available to give assistance if this was necessary. Residents commented on how good the food was in the home: “I always enjoy the meals here” “always good food” “its homely and well cooked”. Residents are always offered a choice; a resident commented “they will always do something different if you ask” and the home are able to cater for individuals who have any particular dietary needs. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear procedures in place and this enables individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing training to all staff in this area. EVIDENCE: The home’s complaint log recorded one “complaint” this was about the cost of chiropody, which had been increased however this was, something the home had no control over. This had been explained to the resident and the manager had looked at other chiropodists but their cost was the same or more. She was also aware that in some circumstances this does still remain a free service ie if an individual is diabetic. In talking with residents they were aware of how to make a complaint though a common response was “I have never needed to” and a number of residents said how “we can always speak to Wendy” and importantly how they felt “something would be done” “they (staff) always listen to us”. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 14 The home has Protection of Vulnerable Adults policy and all staff have completed Vulnerable Adults training. This is mandatory training for all staff. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, comfortable, well-maintained and hygienic environment for the residents and staff. EVIDENCE: The home is well maintained with good quality furnishing and is in general very homely and comfortable particularly the lounges and dining room. One area which could benefit from improvement were the bathrooms these could be more inviting in that they were in the inspector’s view rather cold and lacked any real sense of homeliness. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 16 A number of resident’s rooms were seen and they were well equipped and all had personal items such as pictures and photographs giving them an individual feel. Residents commented on how clean the home always is and on the day of the inspection this was certainly the case. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are satisfactory so that the needs of residents can be met in an efficient way. The training of staff must be improved in making sure all staff complete mandatory areas so that they have the necessary skills and competence to meet residents needs in a safe and competent way. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of residents is protected. EVIDENCE: The staffing of the home is good with 4/5 staff on duty am 8-1, 2 staff on duty pm with a waking night and sleep-in staff available. In addition to care staff the manager or deputy are on duty. The owner of the home advised the inspector of changes in that at present care staff undertake domestic duties however they are planning to have specific domestic staff on duty. This is a positive and welcomed change in that it will enable staff to have more time with residents. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 18 Training records for a small number of staff (8) were looked at and showed some gaps in training: 5 staff had no record of moving and handling training, 4 had no medication training (this needs to be undertaken if staff have any responsibilities in this area) other training had been completed by staff ie fire safety, first aid (though not all). It was also discussed with the manager that no staff had received Care of Substances Hazardous to Health/Infection Control training. In-House training is available to staff including Epilepsy, Managing Continence, Dementia, and Skin Care. At present 7 members of staff have completed an NVQ qualification (Level 2/3) and 3 are planning or currently undertaking this qualification. The manager of the home advised that all new staff are advised at interview that NVQ training is mandatory: this approach is to be commended. Staff recruitment records were looked at and showed the necessary checks and safeguards are in place ie 2 references, application forms shows full information including employment history, Criminal Record Checks (CRB) are undertaken. Staff complete an induction programme on starting of their employment. All staff in the home have had CRB checks and these were seen on this inspection. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good opportunities for residents and others to express their views about the service they receive. The practices of the home help to make sure that the health, safety and welfare of residents and staff are protected. EVIDENCE: The manager Mrs Pullin has extensive experience of working with older people having worked at Collingwood for over 18 years originally coming to the home as a care assistant. She has completed NVQ 4 Registered Manager’s Award and is a qualified NVQ assessor. The inspector found her to be approachable and Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 20 residents also commented on how they could always “go to talk to her about anything” a member of staff also commented very positively on her open and honest approach. There is clearly a real effort on the part of the manager and recently appointed deputy to work closely in making and continuing to make any improvements in the quality of care in the home. The deputy has nursing experience and though not employed in this capacity this has added to the home’s level of expertise and experience and can only be of benefit to residents. As mentioned previously in this report the home has introduced a Quality Assurance questionnaire for residents, which will be used to get the views of residents about the quality of care they receive. The current questionnaire has previously been available to relatives and with the changes discussed with the manager will be more applicable to issues that are more relevant to residents. Future inspections will look at the results of such questionnaires to inform the CSCI about the care provided in the home and particularly any changes or improvements which have taken place as a result of comments and suggestions received. Residents meeting are held however the inspector was unable to see any minutes or actions taken as a result of such meetings; again this will be looked at on future inspections. In talking with residents throughout the inspection it was very evident from the comments made that there is an atmosphere in the home encouraging residents to express their views and voice their opinion. It is the home’s policy not to manage resident’s financial affairs. Fire records showed that weekly fire alarm and monthly emergency lighting tests are completed. A fire risk assessment has also been completed. Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 21 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 3 X X X X 3 Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 13(5) Requirement Ensure there are suitable arrangements to provide a safe system for moving and handling residents. (Moving and Handling assessments to be completed as part of care plan so that the appropriate safe way of moving and handling residents is identified and recorded) All staff receive training appropriate to the work they are to perform. (This relates to the need for Moving & Handling COSHH/Infection Control) The home to establish with the individual or representative their wishes and feeling on their death. (This relates to recording such wishes as part of individual care plan) Supply to the CSCI copy of resident’s Quality Assurance questionnaire and report giving results and any actions taken. Timescale for action 30/11/06 2 OP30 13(6) 18(1)(c) (i) 12(2), 12(3) 28/02/07 3 OP11 28/02/07 4 OP33 24(2) 28/02/07 Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 Page 23 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.V317941.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Collingwood DS0000003320.V317941.R01.S.doc Version 5.2 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. 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