Inspection on 14/09/05 for Collyhurst

This inspection was carried out on 14th September 2005.

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

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

Other inspections for this house

Collyhurst 05/12/08

Collyhurst 04/06/07

Collyhurst 04/09/06

Collyhurst 16/01/06

Collyhurst 14/10/04

Collyhurst 08/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Collyhurst 31-33 Nuneaton Road Collycroft Bedworth Warwickshire CV12 8AN Lead Inspector Louise Thompson Unannounced Inspection 14th September 2005 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 Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 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. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Collyhurst Address 31-33 Nuneaton Road Collycroft Bedworth Warwickshire CV12 8AN 02476 319092 02476 319092 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) Mr K Taylor Mrs Elizabeth Taylor Mr Charles George Taylor Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (21) Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Any admission of a person under the age of 65 shall be agreed with the Commission for Social Care Inspection in advance. 14th October 2004 Date of last inspection Brief Description of the Service: Collyhurst Home is a family owned and run care home, which is situated in the Collycroft area of Bedworth. The home is registered to provide care for the older person and one younger adult with specialist needs. Collyhurst is located on the main road, which links to the two towns of Nuneaton and Bedworth and is very convenient for local services, hairdressers and shops, and a community centre, which is within close walking distance. Accommodation is provided both in the main building and a small bungalow, which is situated to the rear of the property. Service user accommodation is comprised of 18 single rooms and 2 shared rooms. The bedrooms in the main house are accessible via a passenger lift or stairs. The bungalow has it’s own small kitchen and lounge facility and accommodates up to four residents. There are pleasant garden areas at the rear of the home, which are accessible to all current residents. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. This was the first visit for this inspection year. Staff co operated fully with the inspection. The manager and deputy manager were present throughout the inspection. The inspection process involved a tour of the home, talking with the manager, examining records and care plans, observation of care practices along with discussions with residents and staff. What the service does well: 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 contacting your local CSCI office. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 6 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 Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 7 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): These standards were not assessed as part of this inspection. EVIDENCE: Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 8 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): Standards 7, 8, 9 and 10. There is a suitable care planning system in place, which provides the staff with the necessary information to meet individual residents needs. Health needs of residents are met with evidence of liaison with health and social care professionals on a regular basis. The current system for entering some medications on the MAR sheet has the potential to lead to discrepancies in administration of medications. Personal support is offered in such a way as to maintain residents’ privacy and dignity. EVIDENCE: Individual care plans are available. Inspection of the records of three of the residents showed that the health, personal and social care needs are identified and planned. Care plans and risk assessments are reviewed on a regular basis. Evidence of resident involvement in care reviews was seen on those files examined. Access is available to health professionals outside of the home, which includes the Chiropodist, GP, District nurses and the Dentist. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 9 Care files viewed showed involvement of members of the multidisciplinary team in assessing and meeting residents’ care needs. Good evidence was seen of involvement of the Diabetic Liaison Nurse and District Nurses with the management of two residents with diabetes. This included staff training, risk assessments and observation of staff skills. Residents said that the staff were very nice and that they felt well cared for. Systems for the management and administration of medications were observed and were generally satisfactory. The following issues were identified and discussed: • • • Two medicines written by hand did not specify dosage of drug and frequency of administration. Records demonstrated that these had been administered on a regular basis. Not all medications prescribed as required indicated reasons for their administration. Policies for management and administration of medication needed further development. Residents spoken with said that the staff respect their privacy and dignity. Staff gave personal care in private. Residents said they can choose to spend time alone in their bedrooms and their privacy is respected. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 10 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): Standard 13 People living in this home are supported to maintain family links and friendships and continue to be part of the local community in which they live. EVIDENCE: There are no restrictions placed on visiting unless requested by residents. Four of the residents said that visitors are welcome at any time and that family and friends can arrange to take meals with them when visiting should they wish. Several of the current residents continue to access the local town and its facilities. One resident said that she regularly attends town and had been out that morning shopping for new clothes. Three of the residents were attending the local hairdresser on the afternoon of the inspection. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 11 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): Standard 16 Systems for the management of complaints are satisfactory residents can be confident that their concerns are listened to, taken seriously and acted up on. EVIDENCE: Residents told the inspector that if they had any concerns about any aspect of the service they would discuss these with the manager. The complaints procedure is located in the hallway and is included in the Service User Guide. There were no complaints recorded in the home’s complaint register since the last inspection. The CSCI has received one complaint since the last inspection visit this was not upheld. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 12 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): These standards were not assessed as part of this inspection. EVIDENCE: At the time of this inspection visit the home was observed to be clean and tidy and free from odours. Plans to improve the current facilities for people living in the home have been submitted to the local planning department for approval. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 13 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): Standard 27, 28 and 29. The number and skill mix of staff is sufficient to meet the needs of residents. The recruitment procedure must be more robust to ensure the protection of those living in the home. NVQ training is promoted within the home. EVIDENCE: During the inspection there were three care staff on duty, the manager, deputy manager, domestic and catering staff. Duty rotas observed for the period of a month demonstrated that staffing levels were maintained. Discussion with staff and observation showed that they are a well-established team, knowledgeable in the needs of the older person and in sufficient numbers to meet the needs of the current residents. Residents spoke highly of the staff and manager saying, “nothing is too much trouble, you ask and it is done” and “the staff here are lovely” At the time of this inspection all of the care staff had achieved NVQ level 2 or above the manager and staff are commended for this. Files of three staff members were observed all contained evidence of suitable CRB checks. Only two of the files contained two references, the manager said that references had been obtained for the third but had not been filed. None of the files contained evidence of personal identity. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 14 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): Standard 35 and 36 Residents’ financial interests are safeguarded. An appropriate system for staff supervision needs to be implemented to ensure that staff has the support, skills, practices and knowledge to meet all of the residents needs. EVIDENCE: Residents are encouraged to manage their own finances with support from family members, legal representatives and advocates where necessary. Records of monies held in safekeeping by the home were observed for two of the residents and were found to be correct. Access to resident accounts is restricted and lockable facilities are provided. The manager said that staff are currently supervised on a daily basis by the manager/senior care staff however this is largely informal and records are not kept of these supervisions. Staff have an annual appraisal with records of these seen on two staff files. An appropriate system for formal supervision needs to be implemented with records maintained. Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 15 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 4 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 2 X X Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 16 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 OP9 Regulation 13 Timescale for action The registered person shall make 31/10/05 arrangements for recording, handling and safe administration of medications received into the care home. The registered person must 31/10/05 ensure that two references are obtained prior to employment and that information and documents in respect of that person has been obtained as per Schedule 2 Care Homes Regulations 2001. The registered person must 31/12/05 ensure that an appropriate system for formal staff supervision is implemented and care staff receives a minimum of six supervisions each year. (Old timeframe of 30/03/05 not met) Requirement 2 OP29 19, 17 Schedule 2 3 OP36 18 Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 17 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 OP9 Good Practice Recommendations The inspector recommends that the policies for the management and administration of medication are reviewed and that a copy of The Administration and Control of Medicines in Care Homes and Children’s Services is obtained. (Royal Pharmaceutical Society of Great Britain June 2003) The inspector recommends that lockable filing cabinets are provided for the safe storage of records and individual files. 2 OP37 Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Collyhurst DS0000004206.V249784.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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