Inspection on 16/01/06 for Collyhurst

This inspection was carried out on 16th January 2006.

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

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

Other inspections for this house

Collyhurst 05/12/08

Collyhurst 04/06/07

Collyhurst 04/09/06

Collyhurst 14/09/05

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 Michelle O’Brien Unannounced Inspection 16th January 2006 8.15 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.V278504.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 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.V278504.R01.S.doc Version 5.1 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 September 2005 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.V278504.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the inspection year (April 2005 – March 2006) and was unannounced. The inspection took place over 6½ hours commencing at 8.15am. The focus of this inspection was to assess the standards not assessed during the previous inspection. For a full overview of the home this report should be read along with the inspection report of 14th September 2005 On the day of inspection there were 21 residents being cared for in the home. The inspector had the opportunity to meet most of the residents by spending time in the communal lounge and talk to six of them and one relative about their experience of the home. Many of the residents were articulate and able to express their opinion of the service they received to the inspector. General conversation was held with other residents along with observation of working practices and staff interaction with residents. The inspector joined residents for their midday meal. Documentation maintained in the home was examined and this included care files of residents, staff personnel files and training records, policies and procedures and records maintaining safe working practices. The registered manager was present during the inspection and co-operated fully with the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 6 Care plans must be available for all the identified needs of individual residents and must be regularly reviewed to ensure that any change in needs is not overlooked. The policies for the safe administration of medicines need to be reviewed and brought up to date to reflect current legislation and best practice recommendations. Action must be taken to reduce the risk to residents from unguarded radiators. The requirements identified in the Environmental Health Officer’s report of October 2005 to improve the kitchen must be addressed. A system for monitoring working and care practices needs to be in place to maintain, measure and improve the quality of service delivered to residents. Staff must have regular training in fire safety to ensure the safety of people in the home. 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.V278504.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 5 was assessed. Residents have their needs fully assessed before admission to the home to ensure that their needs can be met by the home. EVIDENCE: A detailed assessment form reflecting the areas of assessment contained in the National Minimum Standards has been developed by the home. This is used to gather information about prospective residents’ needs prior to moving into the home The care files of three residents were examined and all relevant information was found to be collected. The community care plans provided by the social worker were seen within the residents’ care plans. Each resident’s care plan is developed using the information from the initial assessment. One resident spoken to described having a previous short stay in the home and said that helped him and his family choose this home when he needed to move into a care home. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 and 9 were assessed. Residents’ care plans do not contain the necessary information to meet all of the identified needs of residents and are not consistently updated when needs change. This puts residents at risk of not having all of their needs met. Medicines are safely administered to residents but the policies for the ordering, receipt, storage, administration and disposal of medicines need to be reviewed and updated to protect residents from potential harm. EVIDENCE: When the inspector arrived at the home many of the residents were already up and dressed and in the lounge or the dining area having breakfast. All the residents were appropriately dressed in well-laundered clothes and looked well groomed. It was evident that there are people with varying levels of need in the home. Some residents required assistance from staff to get up out of their chairs and supervision to walk with their zimmer frames; other residents mobilised independently and moved about the home freely. Residents made positive comments about the care they received and said, ‘Staff are helpful’. Staff and residents were observed to have a good relationship. Residents called staff by name and were comfortable about asking for assistance. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 10 It was evident from examination of residents records that the information gathered during the assessment process is used to develop a plan of care for each resident; however, the care plan files of residents were generally disorganised and difficult to follow. The service has recently developed, and is in the process of, implementing a new format of care plans. Some of the residents’ files contained plans in both the old and new format, which gave conflicting information for the same, identified need. This presents a risk of staff not being able to access the information necessary to deliver appropriate care to residents. The care files of three residents were examined and all of them contained directions to enable staff to meet some, but not all, of the identified needs of residents. Some of the plans did not reflect a change in the residents’ need; for example, the file of one diabetic resident stated that tablets controlled the diabetes but this had changed and the resident was having insulin to control the diabetes. The service demonstrates good practice in the use of risk assessment tools to monitor the development of pressure sores, nutrition and moving and handling with a numeric scoring system. Documenting whether the score indicates a low, medium or high risk could develop this further and this would assist in the development of appropriate care plans. The practice for the administration of medicines to residents are safe. Staff receive training in the administration of medicines. Staff spoken to were knowledgeable about the medicines administered to residents and were able to identify the action of certain drugs during discussion with the inspector. Medicine administration records were maintained. The service uses a monitored dosage system for administering medicines with cassettes that are changed weekly. The temperature of the fridge for storing medicines exceeded the recommended temperature and needed to be defrosted. Storage of medicines at incorrect temperatures carries a risk of changing the action of the medicine. The manager was able to describe in detail the procedures for the ordering, receipt, storage, administration and disposal of medicines however the medication policies for the home need to be updated to reflect current guidance from the Royal Pharmaceutical Society. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. The current arrangement for activities and entertainment are limited and so therefore do not provide adequate recreation or motivation for residents which may result in boredom and low self-esteem. The service supports residents to have choice and control over their life which promotes independence and enhances their quality of life. Meals provided are varied and provide a balanced diet for residents. EVIDENCE: The interests of residents are recorded in their care files but the home has no planned activity programme. It was informed that activities such as board games take place on a day-to-day basis but no evidence of this was seen on the day of inspection. The inspector was told of performers coming in to the home to provide entertainment for residents. The residents are supported to maintain links with the local community and one resident told the inspector that she takes the bus into town independently. Some other residents go out to attend life skill classes such as ‘Cooking on a Budget’, which promotes their independence. Residents are supported by staff to attend the hairdresser, which is a short distance from the home. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 12 Residents were observed to receive visitors both in the communal areas and the privacy of their own room. Staff were welcoming and friendly towards visitors to the home; a relative spoken to said, ‘We wouldn’t be anywhere else’. One resident described how she maintains strong links with her family by staying overnight with them for one night each week. The inspector joined residents for their midday meal. The choice of meal was faggots or crispy pancakes and this was accompanied by mashed potatoes, carrots and cabbage and was followed by rice pudding. The meal was quite a social occasion although one resident did comment, ‘I’m told where to sit’. The meal was warm and well presented and residents chatted over their lunch. The inspector visited the kitchen and inspected menus and food temperature records. There was a cleaning schedule for the kitchen but there are no records of whether or not it is done. Plenty of good quality produce was seen in the food stores of the home. The issues identified during the last inspection by the Environmental Health Officer need to be addressed and this includes some repairs to the fabric of the kitchen wall and floor. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 17 and 18 were assessed. Residents are supported to participate in the civic process. A vulnerable adults procedure is in place but staff have not had update training in how to respond to suspicions of abuse. This potentially leaves residents who use the service at risk. EVIDENCE: The service supports residents to exercise their civic rights during local and general elections by taking them to the polling station or arranging postal votes. A procedure for responding to allegations of abuse is available with clear guidance for staff. It was evident from discussion with the manager that he is fully informed of the local Social Services policy for dealing with allegations of abuse. However, staff need to have training in Abuse Awareness and how to respond to suspicions of abuse in order to ensure the protection of residents. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 14 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): Standards 19, 20, 24, 25 and 26 were assessed. The home is in need of improvements to provide safe, comfortable surroundings for residents to enjoy. EVIDENCE: On the day of inspection most of the residents used the large communal lounge, which also incorporates the dining area. This was bright and airy with lots of natural light from the large windows and patio doors, but some of the armchairs looked worn. A staff member accompanied the inspector during a full tour of the home. The majority of bedrooms were seen and these were found to be comfortable and personalised with residents’ own belongings. Privacy screens were available in shared rooms. One resident had taken the opportunity to have satellite television installed in his room. Screening was available in the shared rooms. Each of the rooms has it’s own telephone point and the home has a payphone that residents can use. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 15 There were no offensive odours in the home. The décor and fabric in some parts of the home needs to be updated but the owners are awaiting local planning department approval of plans to extend and improve current facilities in the home. The issues identified during the last inspection by the Environmental Health Officer need to be addressed and this includes some repairs to the floor/wall junction in the kitchen. Most of the home looked clean but some the small kitchen area adjacent to the lounge was dirty Action must be taken to reduce the risk of harm to residents where radiators do not have guaranteed low surface temperatures. Suitable protective clothing is available for staff use for the control of infection. The home has a small laundry room with suitable equipment for managing dirty laundry. The laundry was untidy and there were cleaning chemicals that should be locked away. The inspector discussed considering the use of single use laundry bags with soluble strips to ensure minimal handling of soiled laundry and reduce the risk of cross infection. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 16 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): Standards 29 and 30 were assessed. Recruitment practices are sufficient to ensure the protection of residents. Staff were observed to be competent to do their jobs and have planned training that could result in appropriate care being given and an increase in the quality of life for residents. EVIDENCE: The personnel files of two recently employed staff were examined and these were found to contain the necessary pre-employment checks such as references, Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (PoVA) to ensure the protection of residents. The home has an induction programme for new employees that meets National Training Organisation standards. Training records were available to demonstrate that staff have accessed training in continence, medication, dementia awareness, falls management, challenging behaviour, diabetes and Parkinson’s disease. The inspector spent time in communal areas observing staff working practices and their interaction with residents. Staff were attentive to the needs of residents, gave prompt assistance when a resident requested and anticipated the needs of some of the frailer residents who may have poor insight to their Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 17 own needs. Residents made positive comments about the staff group, saying they were ‘helpful’ and ‘kind’. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 18 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): Standards 31, 33, 36 and 38 were assessed. The manager of the home is qualified and competent to guide staff to ensure residents receive consistent quality care. The home has no method of monitoring the quality of service that the residents receive, which makes it potentially difficult to maintain and improve standards. Staff supervision is provided but is not consistent or structured and therefore gives no clear picture of development or training needs. The health, safety and welfare of residents is promoted but this could be improved by further staff training. Records, policies and procedures are adequately kept to safeguard resident’s interests. EVIDENCE: Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 19 The manager of the home has 18 years experience in care of the elderly and has managed the home for 2 years. His qualifications include NVQ level 4 in care and the Registered Manager’s Award (NVQ level 4). The manager was unable to demonstrate any method of auditing working practice to monitor standards or enabling residents to express their views. The inspector discussed with the manager how this could be implemented to ensure the home is run in the best interests of residents. The home’s maintenance records and personnel files were organised and maintained. Some of the residents’ care files examined did not contain necessary information. Records were examined to establish safe working practices within the home. These included contracts and servicing documentation for electrical equipment, gas, clinical waste and all other services supplied to the home. Resident aids and equipment have been serviced, this includes hoists and baths and maintenance work is up to date. Fire records are up to date and the lift has been serviced and is currently in good working order. Records for the testing of portable electrical appliances were available and were up to date and the Periodic Fixed Electrical Installation Inspection was done in December 2002 with the recommendation that the next inspection should be done in 5 years. The health and safety of people in the home is promoted by a planned programme of statutory training for staff in moving and handling, food hygiene and infection control. It was informed that Fire Safety training for staff is informal. Mandatory training for staff must be reviewed to ensure that staff receive adequate training in Fire Safety. Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 20 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 2 3 3 X X X 3 2 2 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 1 2 2 Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 21 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 OP37OP7 Regulation 15, 17 Requirement The registered manager must ensure that care plans are written to describe in detail the actions required to meet all the current needs of residents in respect of their health and welfare and the plans must be kept under review The registered manager must make arrangements for recording, handling and safe administration of medications received into the care home. This is outstanding from the previous inspection and requires urgent attention The registered manager must ensure that there are organised activities that reflect the residents’ social, cultural and interest needs. The registered person must ensure that the risk to residents from unguarded radiators is reduced. The registered person must ensure that all areas of the home are kept clean and the issues identified in the Environmental DS0000004206.V278504.R01.S.doc Timescale for action 31/03/06 2 OP9 13 31/03/06 3 OP12 16 30/04/06 4 OP25 13, 23 31/03/06 5 OP26 16, 23 30/04/06 Collyhurst Version 5.1 Page 22 6 OP33 24 7 OP36 18 8 OP38 23 Health Officer’s report are addressed. The Registered Person must introduce systems that will effectively monitor and audit working and care practice in the home. These procedures must be ongoing. The registered manager must ensure that an appropriate system for formal staff supervision is implemented and care staff receives a minimum of six supervisions each year. This is outstanding from the previous inspection and requires urgent attention The registered person must make arrangements for staff working in the care home to receive suitable training in fire safety. 31/05/06 30/04/06 28/02/06 Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 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) Collyhurst DS0000004206.V278504.R01.S.doc Version 5.1 Page 24 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.V278504.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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