Inspection on 23/04/04 for Collins House

Care Home For Older PeopleCollins HouseSpringhouse Road Corringham Essex SS17 7LEUnannounced Inspection23rd April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Collins House Address Springhouse Road, Corringham, Essex, SS17 7LE Email address Name of registered provider(s)/company (if applicable) Thurrock Council - Mrs Christine Lesley Paley Name of registered manager (if applicable) Mrs Alice Bell Type of registration Care Home No. of places registered (if applicable) 45 Tel No: 01375 671162 Fax No: 01375 361065Category(ies) of registration, with (number of places) Older people 23, Dementia 22 Registration number I060000266 Date first registered 30th July 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2003 NO YES 13/05/03 If Yes refer to Part CCollins HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 323rd April 2004 10:00 am Mr Trevor DaveyID Code072090Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionN/A Judith A McKiernanCollins HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementCollins HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Collins House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Collins HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Collins House is situated close to Corringham Shopping Centre and local facilities. There is a regular bus service to near by places of interest and the home is in close proximity to the railway station. Collins House is a purpose built establishment that was refurbished 8 years ago. Service users accommodation is on the ground and first floors and a shaft lift is available. The home is owned by Thurrock Council and registration has been granted to provide care for 45 older people over the ages of 65 which includes a registration category of dementia for 22 places. There is provision for 41 single and 2 double bedrooms and in addition, there are a variety of seating areas throughout the home. Service users have access to a secure garden that has comfortable seating facilities.Collins HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Collins HousePage 6 This service has been inspected as required under the Care Standards Act 2000 and the Care Homes Regulations 2001 (as amended). Areas to be progressed are listed in the requirements and recommendations section of the report. Any breaches in regulations that pose a more immediate risk to service users have been highlighted for urgent action. Not all standards will have been assessed at this inspection. Standards not assessed during this inspection will be covered at the next inspection. Records practices policies and procedures have only been sampled. At future inspections other issues may come to light when different items are sampled or different people are spoken to. This home is within the public sector and the previous inspection highlighted a number of requirements and recommendations many of which, have been implemented or are in the process of being completed in accordance with the homes action plan. CHOICE OF HOME (Standards 1 ­ 6) Two of the two standards assessed were met. A sample check was made of pre admission assessments which had been completed for recent service users admitted to the home. A new post has been created of care manager who is responsible for carrying out pre admission assessments and visiting potential service users. Care plans had been compiled and included relevant information regarding all aspects of care as well as details of personal interests, cultural and religious issues. HEALTH AND PERSONAL CARE (Standards 7 ­ 11) One of the three standards assessed was met. A care plan had been drawn up for each service user and the management had updated the format . The process of transferring information contained within the previous system was taking place. Various aspects of care including nutrition, sensory impairments and moving and handling assessments had been recorded and regularly reviewed. From the sample check made, any identified problems together with the aim and plan to meet these needs had been recorded. Overall, the administration of the medication was being maintained in accordance with required procedures. Additional measures were identified by the inspector which needed to be included in accordance with good practice and providing appropriate safeguards. From an examination of the care plans and personal records, it was noted that some of the risk assessments had not been completed or updated and advice was given by the inspector regarding additional information which should be included. The inspector was also advised that a number of staff have not received training on risk assessment and this should be addressed by the management as this is seen as an important part of the process for ongoing care practice. DAILY LIFE AND SOCIAL ACTIVITY (Standards 12 ­ 15) The one standard assessed was met. From conversations with service users, staff and general observation, service users were enabled to adopt their own daily routines and personal lifestyle so far as it was possible. One of the care staff had specific responsibility for heading up the social activities programme and particular provision had also been made for service users who had been identified with dementia. Some outings are also arranged and service users spoken to were positive regarding the choice and degree of independence they were able to enjoy. COMPLAINTS AND PROTECTION (Standards 16 ­ 18) Three of the three standards assessed were met. No recorded complaints had been received by the home during the previous 12 months but a number of letters and expressions of appreciation had been received of the care provided Collins House Page 7 and these were made available for inspection. Adult Protection and Whistle Blowing procedures were in place and the inspector was advised that all staff are to receive training on these procedures beginning in June. ENVIRONMENT (Standards 19 ­ 26) six of the six standards assessed were met. As a home which was operating prior to the 31st March 2002, the accommodation and facilities provided were of a suitable standard and fit for the purpose in respect of service users being accommodated on the day of the inspection. Considerable interior decoration had taken place and the furnishings together with the equipment provided was of an acceptable standard. Communal bathroom facilities included appropriate equipment for hoisting with sufficient space for staff to manoeuvre with some of the more dependent service users. At the time of inspection, the inspector was advised that any dependent wheelchair users were being accommodated in the larger of the single bedrooms. The bedrooms seen on the day of inspection were clean, nicely decorated and had a number of belongings ornaments and photographs on display. STAFFING (Standards 27 ­ 30) Four of the four standards assessed were met. Since the last inspection, staffing levels have been increased and the management structure of the home now includes residential care co-ordinators who are also shift leaders. The current registered manager of the home was on sick leave but the manager of a near by residential home is currently overseeing the home and calls in during the week and in addition, the service manager from Thurrock Council also has regular input. A staff rota was made available for inspection and staff recruitment records are now available for inspection on the premises. Induction training and ongoing staff development records were available for inspection including details of courses completed and certificates awarded. MANAGEMENT AND ADMINISTRATION (Standards 31 ­ 38) Four of the five standards assessed were met. There is considerable experience in the management team of the home and regular input and monitoring is provided by Thurrock Council. There is a good working relationship within the home between the various staff groups and ongoing supervision of care staff has now been delegated to the residential care co-ordinators. A selection of records and other safety certificates were inspected but at the time of inspection, the public liability insurance certificate was out of date. A record was available showing hoists and other mechanical aids which had been tested in February and one of the hoists had been condemned and has not been replaced. The inspector was advised that only two staff were registered firstaiders and arrangements should be made for additional staff to complete this training. Overall, there was a good atmosphere in the home and staff were observed relating well to service users and fulfilling their duties in both a caring and professional manner. Positive comments were received from service users and relatives spoken to regarding the quality of care provided as well as the kindness and input given by staff.Collins HousePage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 OP28 50 of care staff should achieve NVQ level 2 qualification by 2005.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMet (Yes / No)Collins HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 13(4) OP7 The Registered Person shall ensure that up to date risk assessments for all service users are completed, documented and regularly reviewed. The Registered Person shall make arrangements for the procedures for the safe administration of drugs to include a second signature when controlled drugs are administered. In addition a sample list should be made available of staff names and signatures relating to personnel who are responsible for administering medication within the home. (See Royal Pharmaceutical Guidance relating to the administration of medication in Care Homes and Childrens Homes). The Registered Provider must make arrangements to ensure staff receive training in risk assessment in respect of moving and handling as well as other safety issues regarding service users. The Registered Person must ensure that arrangements are in place to provide sufficient equipment for the moving and handling of service users and any equipment which has been condemned must be replaced. 31/07/04213(2) OP9 Schedule 3Immediate313(4)OP3801/08/04413(4)(5)OP3830/07/04Collins HousePage 10 513(4)OP38The Registered Person must make arrangements to ensure staff are trained in first aid. The Registered Provider must make arrangements for the public liability insurance cover of the home to be renewed.31/08/04613Immediate723(4)The Registered Person shall take adequate precautions against the risk of fire including carrying out fire drills with staff (including night staff) on a three monthly basis to ensure immediate so far as is practicable that a clear understanding exists of the procedures to be followed in a case of fire.RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 OP31 OP28 The homes manager should obtain the NVQ Level 4 in Management and Care or equivalent by 2005. A minimum of 50 care staff should be trained to NVQ Level 2 or equivalent by 2005.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Collins HousePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NO YES YES YES YES YES YES NO NO NO YES NO YES 6 2 0 YES YES YES YES 37 0 23/04/04 10.00 7.0Collins HousePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Collins HousePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/Evidence Not assessed at this inspection.YES Standard met? 0Collins HousePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? Not assessed at this inspection.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Pre assessment information was made available for inspection which also incorporates visiting potential service users. From this information care plans had been instigated and as well as including family background information, other aspects of care needs, interests as well and cultural and religious issues had been recorded. Dietary needs had also been recorded as well as measures to be taken in order to maintain a safe environment for service users where this was appropriate. From a sample inspection, care plans had been regularly reviewed and updated. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Wherever possible, the care manager visits potential service users in their own homes or hospital as part of the assessment process and in some cases, service users are given the opportunity of visiting Collins House. Pre admission assessments and the care plans were also in place in respect of service users who attend for rest spite care.Collins HousePage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Collins House does not provide intermediate care.Collins HousePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? At the time of inspection, a new care plan format had been introduced and the records from the previous system were in the process of being integrated into the new format. Some of the sample checks made during the inspection, showed detailed information which had been regularly reviewed and care plans had a record of the identified problem, the aim and plan of personal care. Some of the risk assessments had not been updated and in some cases where risk assessments were in place, further information should have been added to assist in providing a consistent approach in moving and handling techniques. The inspector was also advised that many of the staff had not received training in risk assessment and this topic should be included as part of the overall training programme for care staff together with compiling and managing care plans. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 14 03 Key findings/Evidence Standard met? Details and ongoing records were in place covering health care provided by District Nurses and other health care professionals.Collins HousePage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? A sample check was made of the homes medication administration records which included signatures of duty managers where medication had been administered together with records of new prescriptions and discontinued drugs returned to the pharmacy. Appropriate storage facilities were in place for medication but where controlled drugs were being administered, a second staff signature must be included as a witness that the medication has been handed out. In addition, the sample list of staff names and signatures should be included in front of the medication policy to clearly identify authorised personnel responsible for handling medication in the home. Reference was made by the inspector to the Royal Pharmaceutical Guidance on the administration of drugs relating to care homes and childrens homes. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Standard 11 (11.1 ­ 11.12). 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. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Collins HousePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The inspector was advised that one of the care staff is involved in specifically heading up the social activities programme which includes bingo, indoor hockey and quizzes. Sing-a-longs also take place as well as handy crafts. A number of the service users in the home are diagnosed with dementia or are in various degrees of confusion and reminiscent newsreel videos are used particularly with this group. Service users interests are recorded and as well as group activities, a number of the service users spoken to enjoy their own private space in their rooms and the freedom of choosing how to spend their day. Two of the relatives spoken to commented that some of the service users made Easter bonnets and that the staff had provided a very enjoyable Christmas for the service users. Records were made available for inspection showing residents meetings the last one being the 26th March. Minibus outings also take place wherever possible. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Collins HousePage 19 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Collins HousePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? A complaints record book was available but no complaints have been received by the home in the past twelve months. A number of expressions of appreciation through letters and cards were seen by the inspector.Collins HousePage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? At the time of inspection, the vast majority of service users had relatives who were safeguarding their interests or who acted on their behalf. In other cases Thurrock Council were taking on this responsibility. The management are aware of the advocacy service and that this should be used wherever possible when service users have no means of representation or of anybody acting on their behalf.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? Copies of the Adult Protection policy and Whistle Blowing procedure were in place and the inspector was advised that staff had been given a copy of the Whistle Blowing procedures. Whilst some of the staff have received training on the prevention of adult abuse further staff are receiving training at the beginning of June.Collins HousePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The building and layout of the home is suitable for its stated purpose and is well maintained. Interior decoration has taken place on the ground floor and work is to begin shortly on the first floor. Appropriate measures were in place for the security of the building and the safety of service users.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? st As a home which was operating prior to the 31 March 2002, the sitting recreational dining space is fit for the purpose and includes four large lounges, one smaller lounge and a dining room. An additional dining room is also available and has been used for day care purposes. Service users spoken to appreciated their rooms, the layout and the opportunity of being able to enjoy their personal possessions and interests. Rooms were seen to be clean, and well maintained.Collins HousePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? There are seven communal bathrooms with toilets including Parker baths and hydraulic seats for the conventional baths. All baths are centrally positioned enabling staff to gain access either side as well as being able to use any hoisting equipment. Additionally there are 12 separate toilets for the use of service users which are conveniently located on both floors. Standard 22 (22.1 ­ 22.8) The registered person demonstrates 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. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Collins HousePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 0 0 0 0 24 197 7 1 13 Key findings/Evidence Standard met? st As a home which was operational prior to 31 March 2002, at the time of inspection, the accommodation for service users was fit for the purpose and where room sizes do not conform to the National Minimum Standards for older people the Registered Provider is aware that service users concerned need to be fully aware of the room dimensions and that details of all bedroom sizes must be included in the Statement of Purpose.Collins HousePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The rooms seen on the day of inspection showed that the furniture and fittings required by the National Minimum Standards have been provided. The inspector was advised that two of the service users had the use of their own keys to give them access to their bedrooms.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Since the last inspection protected surfaces to all radiators have been installed and a record of the hot water temperatures had been completed which were checked on a regular basis to ensure these were at a safe acceptable level.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Collins HousePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 27 0 0 needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 15 0 0 No. staff hours allocated No. staff hours allocated No. of staff hours provided 0 0 0 0 0 00 0 0 Standard met? 3Collins HousePage 27 A staff rota was made available for inspection and the names of all personnel shown were working at the time. Since the last inspection staffing levels have been increased because of the high dependency. There are now 8 care assistants plus a residential care coordinator on duty during the waking day and a manager who is super numorary. It is understood that the permanent homes manager is currently on sick leave and the manager from another registered local authority home nearby was overseeing the home and visiting during the week. The service manager for adults at Thurrock Council also calls in and provides input. As well as an administrator and gardener handy man, there are domestic/housekeepers covering the waking day, two laundry staff a cook and an assistant in the kitchen. A number of the staff have worked in the home for some time with little turnover which has helped in the ongoing running and continuity in the service provided. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 1 3 3 Key findings/Evidence Standard met? Since the last inspection, one member of staff has obtained their NVQ level 2 and a further 11 care staff are now studying for this course. Two of the residential care coordinators are NVQ Assessors.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Since the last inspection, the recruitment records have been made available for inspection on the premises. From the sample check made, this included records of criminal record bureau checks and references obtained.Collins HousePage 28 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? An induction programme was in place and records were seen which included topics of training within the National Minimum Standards for older people. The core skills training includes topics which all staff must complete including dementia/challenging behaviour. Other topics covered were recorded as well as training covered in the probation period. Thurrock Council take the lead in arranging any training which is required by staff in the home. Reference has already been made in this report regarding the need for staff to cover training relating to risk assessments.Collins HousePage 29 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Collins HousePage 30 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? Regular monthly visits are made by the Individual Person Responsible under Regulation 26 and the management are endeavouring to obtain regular feedback from service users and relatives to ensure effective quality assurance is put into place as well as improvements as an outcome of this information. All rest spite service users are given a questionnaire to complete at the end of their stay. Little feedback has been received from this exercise but the home are pursuing this process and key workers feedback any comments or information to the management as a result of the talking to service users. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The home is owned by Thurrock Council and there is no reason to suppose that the home is not financially viable.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 5 0 03 Key findings/Evidence Standard met? A spot check was made of the records of personal allowances held for service users and all transactions were seen to be recorded appropriately together with any receipts. Where service users are unable to look after their own finances, this is carried out in the main by their respective family or a representative. Thurrock Council also have jurisdiction over these matters on behalf of few service users.Collins HousePage 31 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Supervision of care staff on a one to one basis now takes place and this process has been delegated to the residential care coordinators. Records completed as part of this process were made available for inspection.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Some risk assessments were in place for the safe working environment and others were in the process of being completed. Other official records required by regulation were in place including safety certificates for gas and electricity services. A record was available showing that hoists and other mechanical aids had been tested in February and one of the hoists had been condemned. This should be replaced by new equipment as soon as possible. A record of fire procedures and checks was made available for inspection but is was noted that the last fire drill with staff took place in February 2004 and the inspector was advised that night staff are very rarely included. All staff who work in the home should be involved in fire drills which should take place at least every three months and the names of staff who are involved should be listed and recorded. First aid boxes were also in place but at the time of inspection, only two staff were registered first aiders. Arrangements must be made for other staff to be trained in first aid in accordance with Care Homes Regulations. So far as control of substances hazardous to health regulations are concerned, an outside agency now comes into the home to provide the equipment and risk assessments together with training for staff which is required. The names of staff attending these courses was recorded. It was noted that the public liability insurance cover expired on 31/03/04 and is due for renewal.Collins HousePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Care home CommentsComplianceYESCondition Older People (23 Places ) CommentsComplianceYESCondition Dementia ( 22 Places ) CommentsComplianceYESCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateMr Trevor Davey Gwen BuckleySignature Signature SignatureCollins HousePage 33 Public reports It should be noted that all CSCI inspection reports are public documents.Collins HousePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 23rd April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCollins HousePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 23rd July 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOCollins HousePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Christine Paley, of Thurrock Council, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: CHRISTINE PALEY (provided) Director of Health and Social Care 29/07/04Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Collins HousePage 37 - 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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