Inspection on 27/02/06 for Collingwood Court Nursing Home

This inspection was carried out on 27th February 2006.

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

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

Other inspections for this house

Collingwood Court Nursing Home 19/11/08

Collingwood Court Nursing Home 12/09/07

Collingwood Court Nursing Home 14/12/06

Collingwood Court Nursing Home 16/06/05

Collingwood Court Nursing Home 06/01/05

Collingwood Court Nursing Home 03/08/04

Collingwood Court Nursing Home 12/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

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

CARE HOMES FOR OLDER PEOPLE Collingwood Court Nursing Home Collingwood Court Rear Of 1-95 Nelson`s Row Clapham London SW4 7JR Lead Inspector Sonia McKay & Mary Magee Unannounced Inspection 27th February 2006 10:00 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 Court Nursing Home DS0000007015.V284683.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 Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Collingwood Court Nursing Home Address Collingwood Court Rear Of 1-95 Nelson`s Row Clapham London SW4 7JR 020 7627 1400 020 7720 1998 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) ANS Homes Limited Mrs Joyce Mabena Care Home 80 Category(ies) of Dementia (52), Mental disorder, excluding registration, with number learning disability or dementia (52), Old age, of places not falling within any other category (28), Physical disability over 65 years of age (28) Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 28 elderly women aged 60 years and above 52 persons aged 55 years and above suffering from organic mental health disorders The 3 current physically disabled patients aged below 65 years To include one person aged between 50 years and 55 years, to be accommodated on either Hazel Wing or Rose Suite 16th June 2005 Date of last inspection Brief Description of the Service: Collingwood Court is a nursing home owned and managed by a care provider called ANS. ANS became a subsidiary of BUPA in August 2005. The home provides nursing care for 80 service users in a purpose built 2-storey unit. It is set in its own grounds on a quiet residential street. The location is convenient to public transport and the local shopping area of Clapham. It has a small but pleasant garden to the rear and limited parking facilities are available. The home has three separate units – two of which are located on the ground floor. The third unit is located on the first floor. Two of the units (one on the ground and one on the first floor) provide nursing care for people with mental health problems/dementia. The third unit is for frail elderly people and people with a physical disability that require nursing care. Each unit has a lounge and dining room. The main kitchen and laundry facilities are located in the basement. A hairdressing room and an activities resource room are available on the first floor. A passenger lift is provided for access to the first floor and the basement and the home is wheelchair accessible. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors conducted this unannounced inspection over one-day. It involved a tour of the premises, examining records of nursing care and talking with 7 service users, 8 relatives and members of staff employed in all areas of the home. What the service does well: What has improved since the last inspection? What they could do better: There must be a more thorough approach to the pre-admission assessment of the needs of prospective service users to ensure that the home is able to safely meet the needs of any service user admitted. Written care plans and risk assessments must be reviewed, updated and completed accurately to better reflect changing care needs. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 6 Pressure relieving equipment must be supplied to service users at risk of developing pressure areas at an earlier stage. Medication must be administered at the correct time to ensure that service users are not in pain or discomfort. There must be better planning and more sensitive support for service users who are dying. The range of activities available should be increased and steps must be taken to ensure that staff are competent to support and encourage suitable activities for service users with dementia or mental frailty. Service users must be provided with attentive assistance to eat their meals if this is required. The number of suitably qualified nursing staff must be increased and staffing levels must be reviewed to ensure that an adequate number of staff are available to support the dependency levels of current service users. Staff must all be trained in assisting service users to transfer safely. The CSCI and the placing authority must be notified of any accidents or incidents that affect their safety of service users. Recruitment practices must better protect service users from potential abuse. Methods of restraint used in the home must be discussed and agreed by families and placing authorities. 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 Court Nursing Home DS0000007015.V284683.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 Court Nursing Home DS0000007015.V284683.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&3 There is progress in ensuring that prospective service users have adequate information to inform a choice to live in the home, although full information is not yet available. Service users have moved into the home without having their needs adequately assessed and, as a result of this, the needs of some of the current service users are not adequately met. EVIDENCE: The statement of purpose was revised in February 2006 and includes all information required by regulation. The revised service users guide is still being developed. (See requirement 1) It is evident that some service users have been admitted without full consideration being given to the suitability of the placement and how their individual needs will be met. For example, there is a shortfall in the number of Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 9 RMNs available yet service users with significant mental health needs and challenging behaviour have been admitted. Discussion with senior managers indicates that positive action is being taken to address this. A new pre-admission assessment process is being introduced and urgent placement reviews have been requested for some service users where reassessment has indicated that their individual needs are not adequately met. In some cases alternative placements are being sought. (See requirement 2) Collingwood Court Nursing Home DS0000007015.V284683.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 Service users health, personal and social care needs are set out in individual plans of care. There is a need to complete these documents with greater accuracy in some cases and to record the involvement of service users and their relatives. Service users health care needs are met, but greater emphasis should be placed on preventative healthcare in some cases. There is a need for improvement in supporting service users nearing the end of their lives. EVIDENCE: Eight individual written plans for care were examined and found to be adequate. Individual care plans are evaluated regularly. Senior managers are currently undertaking a quality audit of individual care plans at a rate of eight individual plans per week. Care plans do not provide evidence that service users and relatives have been actively involved in their preparation. Nurses on duty advised that service users and relatives are encouraged to take part. One service user confirmed that he has been involved in preparing his written care plans and members of Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 11 a service users family spoke of the good work at the home and the benefits their relative had gained since moving there to live. (See recommendation 1) Individual needs assessments are completed without sufficient accuracy in some cases. For example, the calculations and scoring on one tissue viability assessment are inaccurate. (See requirement 3) All service users have access to the homes visiting GP on a regular basis and there is evidence that nursing and care staff liaise with the GP effectively. Staff are vigilant in obtaining prompt advice and consultation with professionals when health conditions change. Notable changes such as bruising and discoloration of skin are noted in care files, but have not report been reported to the relevant care manager or CSCI in all cases. (See requirement 17) Equipment is in place to promote tissue viability. Pressure sores are recorded, monitored and treated effectively. Senior staff monitor the progress of treatment and the results are recorded and photographed each week. However, more preventative action should be taken. For example, staff noted that one service user was developing a patch of reddening skin in the sacral area. There was an unnecessary delay in providing the necessary pressurerelieving mattress and the area of skin had broken down before the mattress arrived. (See requirement 4) Health records are good and show daily progress. Staff keep good records in regard to nutrition and any weight gains and losses. Where service users have a notable weight loss, appropriate action is taken. In addition to encouraging service users with food that they like, some receive supplements following advice from the doctor. One service user has progressed well with this intervention and is regaining lost weight. Direct observation of nurses supporting one service user with a PEG feed provided evidence that clear guidelines are in place (supplied by the specialist team from the hospital) and staff are vigilant on following aseptic precautions. There is a lack of exercise programs for service users who require encouragement and support in this area. The majority of service users were observed to sit for long periods in chairs in the lounge. Service users sit in large groups with insufficient stimulation. The home is not making proper provision for those with dementia or those that are mentally frail. Consideration must be given to introducing an environment that is stimulating and inspiring. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 12 There is evidence that service users have access to hearing and sight tests and appropriate aids where necessary. There is also evidence that service users have access to the services of a chiropodist. Continence assessments are in place and appropriate aids and adaptations are supplied. The homes handling of medication will be examined by the CSCI pharmacist. The report of this inspection will be provided separately. During the previous inspection it was noted that one service user had not been administered pain relieving medication on time. During this inspection it was noted that medication was being administered late by an agency nurse on one of the ground floor units (8a.m. to 10a.m. medications were being administered at nearly 11 a.m.). (See requirement 5) Plans are not in place on how people would like to be treated towards the end of their lives. Individual wishes and views are not recorded. There is not enough consideration being given to the quality of life at this time, especially in the areas of favourite foods and sensitive emotional support. One service users plan identified the need to encourage the service user to express her views and vents her feelings about her illness to an allocated member of staff. This had not taken place. This is particularly important for service users that are approaching the end of their lives. (See requirement 6) The funeral of one former service user was taking place on the day of the inspection. Two service users and two members of staff were attending. A placing authority has expressed concerns that no one from the home had attended a funeral for another service user in the latter part of 2005. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 13 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 & 15 The home is not making adequate activities provision for service users with dementia or those that are mentally frail. Service users receive a balanced diet but some service users are not given adequate assistance to eat their meals. EVIDENCE: There are dedicated activities coordinators and the home has an activities resource room. The range of activities advertised on an activities programme was not taking place on the day the inspection. This was due to a shortage of activities coordinators on the day. The range of activities available is currently under review. Activities take place in the communal lounges and during the summer also in the garden. Some service users particularly enjoy regular visits from the gardener and her pet dog. On the day of the inspection it was noted that the chairs in the communal lounges were arranged in a large circle at the edge of the room. Service users were noted to be under stimulated and had little opportunity for social interaction or recreation. The quality of interaction between staff and service users varied. Some staff were observed to interact poorly and others were attentive and were observed to sing and dance with service users. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 14 (See requirement 7) Meals are served in the dining rooms on small tables. Breakfast was observed. Staff were busy providing personal care to other service users, and there were not enough staff on duty in the dining area to provide the one-to-one assistance with eating that some of the service users required. (See requirement 8) Service user satisfaction with the meals provided was varied. One service user rated the food as 8 out of 10 and another said it was Usually cold and of very poor quality . Service users attending an activity in the community on the day of the inspection were advised that their lunch would be saved for them to have on their return. This did not happen, although service users confirmed that they were able to request a sandwich at night if they were still hungry after supper. The kitchen areas are well staffed and clean. The meals are prepared and taken to individual serving areas in each unit on a trolley in the passenger lift. Food produce is stored appropriately and there is a good system in place for menu choices and special diets (for example, soft, pureed or meals suitable for service users with diabetes). There are a number of African Caribbean service users living in the home and cultural choices appropriate to their personal preferences are available two or three times each week. One service user is preparing to move to more independent accommodation. He has been provided with a small kitchenette to prepare snacks. The kitchenette is adapted to meet his individual physical needs. There is a well-appointed occupational therapy kitchen. It is not in use and is currently used as a storeroom. This is a valuable resource that should be utilised. (See recommendation 2) Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 15 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): Senior managers are taking steps to ensure that service users are protected from abuse. Consideration must be given to the forms of restraint used in the home. EVIDENCE: National minimum standards 16 and 18 were examined and fully met during the previous inspection. However, senior BUPA managers have recently investigated the recruitment practices in the home. Recruitment practices in regards to adequate C.R.B checks on members of staff were found to be inadequate for 25 members of staff. This has serious implications for protecting service users from potential abuse. Remedial action has taken place in February 2006. The required criminal records checks and P.O.V.A First checks are now in place. (See requirement 16) Some service users are restrained in wheelchairs by use of lap belts. The decision to use this form of restraint has been risk assessed but not agreed in a multidisciplinary forum that includes placing authorities, relatives/representatives or advocates. (See requirement 9) A service user sustained a broken bone as a result of a fall when a member of staff using an incorrect sling during a transfer. This resulted in an adult protection meeting. Appropriate action has been taken as a result. Collingwood Court Nursing Home DS0000007015.V284683.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 & 26. The premises are suitable for the homes stated purpose but there is a need for redecoration and refurbishment in a manner that is more stimulating to the service users accommodated. EVIDENCE: The location and layout of the home is suitable for its stated purpose and is accessible, safe and the structure is reasonably well maintained. However, there is significant wear and tear in areas of the interior decoration. Wallpaper is damaged, carpets are frayed in areas and the lighting is poor. The bottom of the bedroom door for room 62 is badly damaged and the carpet is badly cigarette burned. Some service users have apparently pulled down their bedroom curtains. Consideration should be given to an appropriate alternative window covering. BUPA estates management have recently inspected the building and a programme of redecoration and refurbishment is planned. This will be an Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 17 opportunity to redecorate the premises in a manner that is more stimulating and inspiring for service users. (See requirement 10 and recommendation 4) There is a member of staff specifically employed for home maintenance who is able to undertake minor repairs and small areas of redecoration. There is also a gardener who has transformed the homes communal gardens and planted many shrubs and spring flowers. All bedrooms are single occupancy with en-suite bathrooms. Some bedrooms are personalised and individual service users have aids and adaptations in accordance with their individual needs. CCTV cameras are in use but are restricted to entrance areas for security purposes only and do not intrude on the daily lives of service users. The fitting of a substantial garden gate has increased exterior building security. Hot water temperatures are thermostatically controlled and are checked regularly. Records kept show that hot water temperatures are within safe limits. There are industrial laundry facilities available. Laundry is currently sorted in the communal bathrooms. Plans are in place to introduce a more hygienic sorted at source laundry collection system. There is insufficient information available about the need for hand-washing and the previously required staff training in infection control has not yet taken place. (See requirement 12) Collingwood Court Nursing Home DS0000007015.V284683.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 & 30 The needs of the service users currently accommodated are not met by the numbers and skills mix of staff currently in place. Service users have not been supported and protected by the homes recruitment practices although senior staff have taken prompt action to address this serious failure. Staff are inadequately trained to do their jobs effectively in some cases. EVIDENCE: There are three units each accommodating 26 service users. The Diana Unit provides medical nursing care and is staffed with two nurses and five carers during the morning, one nurse and four carers during the afternoon and one nurse and two carers at night. This is a total of 210 nursing hours and 546 caring hours each week. The Hazel unit provides dementia-nursing care and is staffed by one nurse and four carers during the morning, one nurse and four carers during the afternoon and one nurse and two carers at night. This is a total of 168 nursing hours and 504 caring hours each week. The Rose unit provides dementia-nursing care and is staffed by one nurse and four carers during the morning, one nurse and four carers during the afternoon and one nurse and two carers at night. This is a total of 168 nursing hours and 504 caring hours. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 19 At the time of this inspection the home is short of three RMNs. Recruitment is underway and it is hoped that this shortfall will be rectified shortly. The dependency levels of the service users currently accommodated is being reassessed. 12 service users require varying degrees of one-to-one staff support. Senior managers have undertaken to review the skills mix of staff on duty and have already identified that two trained nurses should be on duty in the afternoons on the Diana unit. Observation on the morning of the inspection provided evidence that staffing levels on the Diana unit are inadequate during the morning. Discussion with staff indicated that staff are ill equipped to meet the complex and challenging needs of some of the service users. (See requirement 13) Staff vacancies and annual leave are covered by agency staff. The home also employs administrators, catering staff, housekeeping staff, maintenance staff, activities staff and a gardener. BUPA are in the process of introducing an extensive staff training and development plan. Progress with this plan will be examined during the next inspection. Only 15 of the 77 staff employed have received training in safe moving and handling. (See requirement 14) Staff have not received specific training in meeting the palliative care needs of some of the service users. (See requirement 15) Senior managers have recently investigated the recruitment practices. This investigation revealed that 25 members of staff did not have adequate enhanced criminal records bureau checks and suitable references had not been taken up for one member of staff. The enhanced C.R.B checks and P.O.V.A First checks have been undertaken and recruitment practices have been strengthened. To ensure that all other records required by regulation are in place for current staff, a full audit of recruitment records is required. (See requirement 16) Collingwood Court Nursing Home DS0000007015.V284683.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, 33 & 38 This has been a period of significant change for Collingwood Court. Overall there is indication that senior managers are taking appropriate action to ensure that the home is managed effectively during the registered managers absence. However, there are a significant number of outstanding requirements from the previous inspection report. These requirements must be addressed swiftly to ensure the safety of service users and the quality of care provided. EVIDENCE: The registered home manager was not available during his inspection as she is on extended leave. The CSCI was notified of this absence and the interim management arrangements put in place. Two senior BUPA managers are managing the home on a temporary basis at this time in a job-share arrangement. Both are experienced managers and qualified nurses. This inspection was well facilitated by one of the senior managers and the nurse in charge. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 21 ANS homes were taken over by BUPA in August 2005. There is a significant amount of organisational change going on at this time, including the introduction of BUPA policies and procedures and new care planning and staff training packages. Staff spoken with during the inspection acknowledged that recent changes have been difficult but all spoke positively about BUPA involvement so far and the plans for change in 2006. Accidents and incidents are recorded and the records are maintained in the main office. Examination of these records indicated that the CSCI and placing authorities have not been notified of all accidents and incidents in accordance with regulation. (See requirement 17) A significant number of requirements (7) made in the previous inspection report have not been met within the timescale specified by the CSCI. A representative of the registered provider visits the home on a regular basis and completes reports on the findings of these visits in accordance with regulation. These reports are maintained in the home and supplied to the CSCI Southwark office as required. Collingwood Court Nursing Home DS0000007015.V284683.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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 2 3 X 2 2 2 2 STAFFING Standard No Score 27 2 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X X X 2 Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 Requirement The registered person must make an up to date service users’ guide available to current and prospective service users. The registered person must ensure that, having regard to the assessed needs of the service users, the home is well prepared and suitable for meeting the service users needs in respect of health and welfare. Previous requirement of 30/07/05 not met. The registered person must ensure that care plans are reviewed and updated to accurately reflect change to individual needs and address objectives for personal and health care. Previous requirement of 30/08/05 not met. The registered person ensure that pro active measures are taken to promote tissue viability and reduce the risk of pressure sores developing. The registered person must ensure that drugs prescribed for DS0000007015.V284683.R01.S.doc Timescale for action 30/06/06 2 OP22OP3 14 (1) d 30/04/06 3 OP7 15 (2) & 13 (4) c 30/04/06 4 OP8 12(1) 13(4) 30/04/06 5 OP9 13 (2) 30/04/06 Collingwood Court Nursing Home Version 5.1 Page 24 6 OP11 12(2)(3) (4) 7 OP12 12(3) 16(2)(m) (n) 8 OP15 12(1) 16(2)(i) 9 OP18 13(7) 10 OP24OP21 OP20OP19 23 service users are administered at the time prescribed, particularly pain relieving drugs. Previous requirement of 30/07/05 not met. The registered person must ensure that care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. The registered person must ensure that service users are given opportunities for stimulation through leisure and recreational activities both inside and outside of the home; particular consideration must be given to activities for people with dementia and other cognitive impairments and those with physical disabilities. The registered person must ensure that service users who require staff assistance with eating a meal are given the necessary support. The registered person must review the use of restraining lapbelts in a multi-disciplinary forum that includes relatives/ representatives or advocates. The registered person must ensure that a programme of maintenance and renewal for the fabric and decoration of the building is produced and provided to the CSCI Southwark office. The programme must include: • Improved lighting • Redecoration of walls • Repair of damaged garden path • Replacement of DS0000007015.V284683.R01.S.doc 30/06/06 30/06/06 30/04/06 19/05/06 30/06/06 Collingwood Court Nursing Home Version 5.1 Page 25 • • • • damaged interior bedroom doors Replacement carpeting Repacement all broken toilet seats Suitable window coveringsone in bedrooms that have none Redecoration of damaged/ peeling paintwork in some ensuite bathrooms 31/07/06 11 OP22 23 13(4) 16(2) 12 OP26 12(1)(b) 13 OP27 18(1)(a) 14 OP38OP30 13(4)(b) The registered person must demonstrate that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. The registered person must ensure that staff are trained in infection control, and make proper provision for the care, treatment and supervision of service users particularly those that have contacted MRSA. Previous requirement of 30/08/05 not met. The registered person must ensure that at all times suitably qualified experienced and competent persons are working at the home in such numbers as appropriate for the health and welfare of service users. Previous requirement of 30/08/05 not met. The registered person must DS0000007015.V284683.R01.S.doc 31/05/06 05/05/06 05/05/06 Page 26 Collingwood Court Nursing Home Version 5.1 13(4)(c) 15 OP27 18(1)(c) 16 OP29 19 Sch 2 17 OP38 37 ensure that staff are competent in moving and transferring people safely. Previous requirement of 30/08/05 not met. The registered person must ensure that staff that are providing palliative care receive training specific to this. Previous requirement of 30/10/05 not met. The registered person must complete a full audit of the recruitment records for all staff employed. The findings of this audit must be supplied to the CSCI Southwark office. The registered person must give notice to the commission without delay of any event in the care home, which adversely affects the well being or safety of any service user. Any a notification made in accordance with this regulation should which is given orally must be confirmed in writing. 30/06/06 31/05/06 21/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP12OP15 Good Practice Recommendations The registered person should ensure that the involvement of service users and their relatives/representatives in preparing their individual care plans is recorded. The registered person should utilise the OT kitchen. Collingwood Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Court Nursing Home DS0000007015.V284683.R01.S.doc Version 5.1 Page 28 - 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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