Inspection on 09/10/07 for Collins House

This inspection was carried out on 9th October 2007.

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

Collins House 19/01/09

Collins House 17/09/08

Collins House 09/11/06

Collins House 28/09/05

Collins House 19/04/05

Collins House 04/10/04

Collins House 23/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Collins House Springhouse Road Corringham Essex SS17 7LE Lead Inspector Jane Greaves Key Unannounced Inspection 9th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Collins House Address Springhouse Road Corringham Essex SS17 7LE 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) 01375 671162 01375 361065 farachelle@thurrock.gov.uk Thurrock Council Mrs Judith Anne McKiernan Care Home 45 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (45) of places Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Number of service users to whom personal care is to be provided must not exceed 45. Personal care to be provided to no more than 45 older people over the age of 65. Personal care to be provided to no more than 24 service users with dementia over the age of 65. 9th November 2006 Date of last inspection Brief Description of the Service: Collins House cares for 45 older people, 24 of whom might additionally have been diagnosed with dementia. The home is situated in a residential area close to local amenities and Corringham shopping centre. The home is on two floors and there is a passenger lift to enable access to both levels. There are 41 single and 2 double bedrooms, a large dining room and a number of lounges. There is a secure courtyard garden. The home has a Statement of Purpose and Service User Guide, which have been updated in 2006. These documents, together with the last inspection report are available to residents/visitors in the main hallway of the home. The current weekly fees are £584.92. There are additional charges for chiropody, hairdresser, newspapers/magazines, personal toiletries and taxi fares. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that was carried out on the 9th October 2007 and lasted seven hours. The inspection included: discussion with some of people living at the home; the registered manager; the care manager; residential care co-ordinators; the interim service manager; care staff; visiting relatives; inspection of communal areas, a sample of bedrooms and the kitchen; inspection of a sample of records and policies; observation of activities; and telephone conversations with a random selection of relatives subsequent to the site visit. This report also draws on any other information relating to the home received by the CSCI since the last inspection (e.g. Annual Quality Assurance Assessment, notifications from the home, complaints, internal monitoring reports, improvement plans, etc.). Monitoring of this service by Thurrock Borough Council has identified a number of areas where improvement is necessary to make life better and safer for the people living at the home. There has been an action plan developed in September 2007 to address these shortfalls, the commission has been kept informed. Outcomes relating to 22 Standards were inspected: there were 5 requirements resulting from this inspection, and 5 good practice recommendations have been made. The manager and staff were welcoming, helpful and constructive throughout the inspection. What the service does well: There was a sound system in place to safeguard the personal pocket monies of the people living at the home. The number of care staff having achieved NVQ level 2 or above exceed the recommended ratio. Some people living at the home spoken with as part of this visit reported, • “The staff are very good, I get on well with everybody” • “The girls really work very hard” • “We get nice things to eat” • “Quite a nice place to live”. Some relatives spoken with were very positive about the care provision at Collins House. One person said, “X is better today than when he/she first went there years ago” Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 8 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 Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people considering using a service and their representatives, have the information needed to choose a home, which will meet their needs. EVIDENCE: The policies and procedures for admitting new people to the home were in place and remained subject to regular review. The care manager described a thorough pre admission assessment. The manager and/or the care manager visit the person considering making Collins House their home to make sure that the service is able to meet their individual needs. The pre-admission assessment covers all areas of life however the information recorded needs more detail to accurately reflect ‘person centred’ care. Information about the service is available in the home’s Service User Guide. The home does not offer intermediate care. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning does not always provide all the information to ensure peoples’ health and personal care needs are met. EVIDENCE: The care records of three people living at the home were inspected for evidence of how the home plans and meets personal and healthcare needs. There were a variety of assessment forms covering general needs, moving and handling, risk of pressure areas, behaviours, falls, etc. One person’s care plan sampled did not include a photograph; this was addressed immediately once it was brought to the attention of a staff member. The care plans lacked sufficient detail of the action required by staff to meet a need. For example, one care plan identified that the person needs all personal care seen to with supervision and needs assistance to go to the toilet, but did not describe the level of supervision or assistance required, or what the person could do for themselves. Daily records varied, but did not always identify how a person had spent their day. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 11 The care plans were discussed with the registered manager and care manager, who both acknowledged that there were omissions and inconsistencies in the recording and the plans did not evidence the quality of the care being given. Current practice is that RCCs maintain the care plans; they are not used by the home as working documents but more a paper exercise to satisfy regulation. The care manager reported that ‘care plan’ training was to be delivered to the Residential Care Co-ordinators (RCCs) and care staff to enable them to use the care plans in a meaningful manner. There was evidence that care plans were reviewed monthly. The interim Service Manager had identified the shortfalls with the care plans and there is an action plan in place to rectify this. One section in the care plan referred to activites however there was very little information recorded here. There was a separate folder maintained by the activities co-ordinator containing good information about individuals likes, dislikes and the activities undertaken. Individual risk assessments were included in the care management plan, covering a range of issues, such as moving and handling, pressure areas, falls, weight and nutrition. Records showed that peoples’ health care needs are catered for with regular input from the GP and District Nurse. The registered manager reported that there is a GP surgery held at the home weekly for people to access as they choose. The registered manager reported that the home enjoys excellent support from the district nursing team. People spoken with continued to be very happy with the assistance received from staff, and with the way staff supported their personal and healthcare needs. Although staff were very busy throughout the inspection and had little time for social interaction with people, they were observed to show kindness and respect to the people they were helping. Each person living at the home had a designated Key Worker. Staff training records did not confirm that all staff responsible for the administration of medicines within the home had received refresher training. Records on the day indicated that some staff members had not received any training in the safer administration of medicines since 2003. A discussion was held with the registered manager around the necessity for refresher training in this area to protect the health, safety and welfare of the people living at the home. Breakfast medicines were administered by the RCC in the dining room as individuals came downstairs for their breakfast. This can cause problems as many people also have lunchtime medications; if someone doesn’t get down to breakfast and have their morning medication until 09:30 or 10am then there is insufficient time elapsing before the lunchtime medication is administered. It was noted that blister packs containing tablets were left on a table unattended and the drugs trolley was left unlocked when the RCC gave people their medication. Staff reported that the medication was in their view the whole time and residents were not at risk. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 12 On the day of this visit staff were observed treating people living at the home with dignity and protecting individuals’ privacy. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a limited range of activities within the home and community. People living at the home are not supported to exercise choice around every day life. EVIDENCE: Routines within the home were not always flexible and were arranged around staff and tasks as opposed to the needs of the people living at the home. People living at Collins House have become over compliant with the routine of the home consequently when they are asked if they are happy with their life they respond positively as they have no memory of any other regime. Staff reported that the care delivery sometimes felt like a production line. The staff and management were not able to demonstrate how peoples’ choices were made regarding what time people are ‘got up’ or ‘put to bed’. Staff reported that people were “not allowed to come down to the dining room in their dressing gowns to have their breakfast” if they wished and were “not allowed to have breakfast in bed”. The Management team responded that this was not the case and they had no idea where this ethos had come from. It was reported that all people living at the home “must be dressed and Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 14 downstairs for breakfast by 10am” and that the RCCs insisted that all residents were in bed by 10pm. It was reported that individuals were “not allowed to stay in bed” if they felt like it and an RCC responded “tell her she’s got to get up” when one person had indicated a wish to stay in bed. The management team were not aware of these practices. A menu was on the dining room wall with choices of main meal. On this day the choice was between beef stew and dumplings or breaded lamb cutlets. The kitchens were clean and well equipped, food stocks were ample and of good quality. People spoken with reported “the food is beautiful” and “we have nice things to eat”. Smaller dining areas have been introduced providing people with a more intimate and cosy dining experience. Each lounge had jugs or orange and lemon squash with disposable cups for the residents. Most people did not have the ability to help themselves to drinks; on this day staff were not observed pouring any drinks for people. The home has it’s own hairdressing salon, currently this room appears sterile however the registered manager reported plans to make the room a more pleasant place for the ladies to enjoy their weekly wash and set. Residents’ meetings are held bi-monthly and are advertised on notices around the home. The registered manager reported plans to introduce relatives meetings. Activities such as hand massages, nail painting, bingo, ball games, board games and reminiscence sessions take place Monday to Friday mornings. These are recorded in a separate activities file providing a better picture of how people spend their days at Collins House than the daily records. One person reported that “the sing-alongs are good” and another said, “Exercises would be good” Some outside entertainment was arranged for the people living at the home. One relative said, “more could be done to stimulate the residents, they just seem to sit there all day” During a physical tour of the home it was observed one lounge had the television on with the sound muted and music playing very loudly. The seven people sitting in this room were asleep. During the afternoon it was observed that people were sat watching a children’s’ cartoon. When asked, all the people in the room told the inspector they would like the channel changed and were able to indicate which channel they preferred to watch. The service does not have any transport and consequently the people living there do not have the opportunity to enjoy outings away from the home. It was reported that volunteers support a couple of people to attend church services in the community and there are church services brought into the home. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home felt safe and secure. EVIDENCE: There were letters on file complimenting the staff team for the quality care and kindness shown to people living at the home. The complaints folder included one complaint received regarding the early morning milk delivery disturbing people living nearby. This matter had been dealt with in accordance with the service’s policy and procedure for dealing with complaints. Discussion with relatives provided evidence that where verbal concerns are raised with staff members they are not always passed to the management team and dealt with in accordance with the home’s complaints policies and procedures. A discussion was held with the registered manager around training staff to recognise complaints and to use them in a positive manner to drive forward the quality of the service provision. Training records did not provide evidence that the whole staff team had received up to date training in the Protection of Vulnerable Adults. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at the home would benefit by the home continuing a scheduled programme of refurbishment making the environment a more pleasant place to be. EVIDENCE: A physical tour of the premises was undertaken as part of this inspection site visit. A long period of uncertainty about the future of the home had resulted in only reactive maintenance being undertaken. A programme of refurbishment had now started, two lounge areas had been refurbished at the time of this visit. The general décor in the rest of the home was dated and jaded. During the tour around the home the inspector sat on one person’s bed to have a chat with them and discovered it was very wobbly. This was reported to the manager immediately. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 17 There was an abundance of toilet facilities throughout the building however, many had signs on the doors to say, “Not to be used – please keep locked”. The registered manager reported that these toilets did not have wash hand basins and Thurrock Borough Council had decreed that the facilities should be taken out of service. There were still an ample number of toilet facilities available for the people living at the home. One toilet had pads, wipes and gloves scattered all over the window ledge. A discussion was held with the registered manager around the need to find a storage solution for these items to protect the dignity of the people living at the home. It was noted that toilets and bathrooms had bolts at the top of the outside of the doors. The registered manager reported this was so these rooms may be secured from ‘wandering residents’. A discussion was had with the registered manager around how the practice of locking people out of toilet facilities infringed the basic rights of people. Bathrooms were plentiful, well equipped, clean and pleasantly tiled. Individuals’ bedrooms were individualised with personal possessions brought into the home by relatives. Some bedrooms had very limited space and were too small for hoists and wheelchairs. The beds were mostly hospital style beds. The manager reported that these were more functional than domestic style beds however they did not help towards a ‘homely’ environment. There were a variety of communal spaces for the people living at the home to spend their days. There was a small lounge specifically appointed as a residents smoking lounge. The tour of the home was initially undertaken early in the visit and an aroma was noted on the first floor landing, however this had cleared by lunchtime. The service has an industrial carpet cleaner; this helps to keep the environment free from aromas and a more pleasant place for people to live. It was reported that the home employed 4 Ancillary staff daily: 1 Laundry, 1 upstairs cleaner, 1 downstairs cleaner and one person in the servery. Staff reported that, in practice, there is seldom this number of domestic staff available and often there is just one person to clean the whole home. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff morale continues to be low. The home does not have an effective staff training programme to promote and protect the health, safety and welfare of the people living at Collins House. EVIDENCE: It was noted that 7 care staff were on duty each morning. On the day of this visit 4 staff members were helping people to wash and dress on the first floor of the building, one person was serving breakfast in the dining room leaving two care staff to assist 12 highly dependent people downstairs to wash and dress. Staff reported this was insufficient staff cover as there was nobody available to answer call bells and supervise those residents already washed and dressed. The layout of the building means there are various ‘lounge’ areas dotted around the home, it was noted at this visit that people were often sat in these areas with no staff supervision for long periods of time. A discussion was held with the registered manager around reviewing the deployment of staff to meet peoples’ needs. The staff team indicated reluctance to change their way of working and did not appear to embrace that peoples’ care and support should be delivered in accordance with their needs and wishes and not to fit around staff routines. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 19 One relative reported concern at the procedure of hand over between shifts. “It seems that all staff have to go into this meeting and there is nobody around to help if a resident is desperate to go to the toilet” 23 of the 33 care staff employed at the home have achieved a minimum of NVQ level 2; this exceeds the recommended ratio of 50 of the staff team achieving this qualification. Due to the uncertainty about the future of this care home there had been no new staff recruited since the previous inspection visit. The registered manager reported there were some inconsistencies between the way information was recorded on staff files and this would be addressed at the proposed file audit. Long-term staff sickness had resulted in a large amount of agency staff being used at the home; this had a negative impact on the consistency of the care delivery and the morale of the staff team. One relative spoken with voiced concern that the agency staff did not seem to know how to use the hoists safely and that people were getting their feet and legs knocked. It was reported that the home had been given the ‘go ahead’ to recruit new staff members and this was due to take place imminently. It was reported that an ‘employee of the month’ award was being introduced to encourage staff morale. A staff team training matrix was being developed in accordance with an action plan to address shortfalls identified by a Regulation 26 visit undertaken in September 2007 by the Interim Service Manager. Staff members had been asked to provide evidence of any training they had attended in order that the matrix may be brought up to date. At the point of this visit there were many gaps across all training disciplines necessary to promote and protect the health, safety and welfare of the people living at the home. It was noted that much of the training provided dated back to 2003/4; a discussion took place with the registered manager around the need for refresher training to ensure the staff skills are current. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary experience to run the Home however training, development and supervision of staff is inconsistent and staff lack leadership. EVIDENCE: The registered manager has achieved the Registered Manager’s Award (NVQ level 4 in management) and has registered with the Commission for Social Care Inspection (CSCI). The service has a defined line of management however the care staff team lack direction and this is evidenced by management being unaware of many of the care practices happening in the home. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 Page 21 The CSCI had recently sent the home an Annual Quality Assurance Assessment (AQAA) form to complete: although this had been completed, the information provided did not contain sufficient detail to describe how the home feels it meets the National minimum Standards, or their plans for improvement. The organisation operated a system of monthly ‘person in control’ visits that involved a report being made that reviewed outcomes for people in many areas of their daily life and experiences. These reports were submitted to the commission and contained good detailed information including areas identified for improvement and action plans to address these. The home has regular meetings for staff and residents and it was reported a survey was sent to relatives in June 2006 to ask them their views. At the previous inspection it was agreed that this information, along with views from stakeholders should be collated and an annual development plan produced as part of the quality assurance programme. It was requested that a copy of this report should be sent to the CSCI to evidence that the home is run in the best interests of the people living there. The commission had not received a copy of the 2006 annual quality assurance report for this service and the registered manager was not able to demonstrate that a quality assurance survey had been taken from all interested parties in 2007. The home does not manage the financial affairs of any people living there, but does look after small amounts of money on their behalf. Procedures for managing money were safe and efficient: the home maintained clear individual records, and receipts for all expenditure. In samples checked for two people, the money, receipts and records all balanced, and two staff signed for any money taken out. The registered manager reported that the staff supervision programme had ‘slipped’ over recent times due to long term sickness of the RCCs responsible for this task. However the manager and care manager had undertaken some ‘hands on’ care shifts alongside the care staff to monitor the quality of care delivered. The home had a clear health and safety policy statement, and additional information and guidance on various aspects of health and safety. Certificates providing evidence of insurance cover, gas safety checks, lift and hoist servicing etc were displayed on the notice board behind the reception desk. Evidence was available to confirm that the home reached a satisfactory standard of fire safety in March 2007. Records indicated significant shortfalls in the training and refresher training in fire safety, health and safety, infection control, 1st aid, manual handling and food hygiene. This means that residents and their representatives cannot be assured that their safety and welfare is adequately promoted and protected. Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Collins House DS0000036411.V352675.R01.S.doc Version 5.2 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 OP7 Regulation 15(1) Requirement Peoples’ assessed needs and specific details of how those needs are to be met must be clearly recorded in a plan of care for care staff to follow. Care staff responsible for administering medicines must receive training/refresher training to ensure their skills are up to date to protect and promote the health and safety of the people living at Collins House. The registered person must ensure people are not placed at risk of harm or abuse. This refers to the training of all staff in this area This is a repeat requirement that did not meet with the agreed timescale of 01/02/07 Timescale for action 31/01/08 2. OP9 13(2) 31/12/07 3. OP18 13(6) 31/01/08 4. OP30 18(1)(c) There must be enough suitably 31/01/08 qualified, competent, trained and experienced persons working at the home to meet the needs and DS0000036411.V352675.R01.S.doc Version 5.2 Page 24 Collins House 5. OP38 12(1)(a) protect the people living there. The home must be conducted to 31/01/08 promote the health and welfare of residents, visitors and staff. This means providing Fire safety training, Manual handling training, Induction training, infection control training, First Aid training and health and safety training for the staff team. 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 Refer to Standard OP14 Good Practice Recommendations It is recommended that the routines of the home are arranged around the choices of the people living there and not task orientated routines. It is recommended that the person in charge continue to progress the programme of refurbishment to make the home a more pleasant place for the people living there. It is recommended that the person in charge review the deployment of staff around the home at times of peak activity to promote and protect the safety and welfare of the people living there. It is recommended that the management structure is reviewed to ensure that the care staff are receiving the support they need to best meet the needs of the people living at the home. It is recommended that the person in charge ensure the staff team receive appropriate supervision to enable them to provide the best possible care and support to the people living at the home. 2 OP19 3 OP27 4. OP31 5. 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