Inspection on 23/05/06 for Colne House

This inspection was carried out on 23rd May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colne House 15/08/07

Colne House 16/05/07

Colne House 04/01/06

Colne House 08/09/05

Colne House 22/03/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Colne House 22 Manchester Road Slaithwaite Huddersfield West Yorkshire HD7 5HH Lead Inspector Alison McCabe Key Unannounced Inspection 23rd May 2006 10:50 Colne House DS0000062797.V296143.R01.S.doc Version 5.2 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 Colne House DS0000062797.V296143.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 Adults 18-65. 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. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colne House Address 22 Manchester Road Slaithwaite Huddersfield West Yorkshire HD7 5HH 01484 844775 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) Bridgewood Trust Limited Mrs Eileen Field Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. New admissions into the home should be for residents with a learning disability who are under 65 years. 4th January 2006 Date of last inspection Brief Description of the Service: Colne House is registered to provide accommodation and personal care for up to eight adults with learning disabilities. The home was taken over by the Bridgewood Trust in December 2004. The Bridgewood Trust is a local voluntary organisation providing a range of services to people with learning disabilities. Colne House is a substantial stone-built, three storey, detached property set in its own grounds on the outskirts of Slaithwaite, a pennine suburb of Huddersfield. Access to the property is via steps and a steep driveway. Parking is available to the rear of the property. An external lift and external steps with appropriate lighting and handrails have been installed since the last inspection to enable residents with physical disabilities to access the home more easily. The current scale of charges at the home was stated to be £615.00. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection a site visit was conducted at Colne House by two inspectors between the hours of 10.45am and 6.50pm. In addition to the site visit, information used to inform the inspection includes notifications received from the home about any accidents, incidents or events that affect the well being of residents; provider monthly visit reports submitted to CSCI; the preinspection questionnaire submitted to CSCI prior to the site visit; completed questionnaires from residents, health professionals and a relative giving views about the quality of the service. Eight resident questionnaires were sent to the home. The acting manager has explained that only six of the residents were able to complete the questionnaire with support. Questionnaires were also sent to: five relatives - two have been returned; one health professional - one has been returned; two social workers - none have been returned. Comments and feedback have been included within the main body of this report although the general feedback from all has been positive with all respondents expressing satisfaction with the service provided at Colne House. As part of the site visit, the inspectors had the opportunity to talk to five residents, three members of staff, the acting manager and the residential services manager. Communal areas of the home were seen and one resident’s bedroom. Records relating to residents and staff training were examined and the medication was seen. The inspectors also had the opportunity to observe care practice and the evening meal being served. Although there remain a number of requirements and recommendations that need to be addressed, the staff and management have made significant progress in some areas since the last inspection visit. The home is going through another period of change as the registered manager has left and a new manager has been appointed. However, staff morale appeared to be good and residents reported being happy at the home and appeared to be well cared for. The inspectors would like to thank the residents and staff for their co-operation and hospitality during the site visit. What the service does well: Before residents move into the home, their needs are properly assessed. Residents are given information about the home before they move in. This helps to make a decision about whether or not to live at Colne House. Residents are supported to make decisions and staff respects their rights. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 6 Good support is offered to enable residents to maintain contact with family and friends. Staff offer good support to residents to go out to work, college, day centre and community based leisure activities. There are also activities available in the home to keep residents occupied. Policies and procedures are in place to protect residents from abuse. A clear complaints procedure is in place and most residents know how to use it. Residents live in a comfortable, clean home with plenty of space. Staff receive relevant training on a regular basis. The home has good recruitment practices and procedures to make sure that all the necessary checks are carried out before staff work at the home. Good systems are in place to seek the views of residents about the service they receive. What has improved since the last inspection? Staff are now keeping detailed daily records and records of contacts with health professionals, family etc. This helps to check that residents’ identified needs are being met. Staff are keeping detailed records of what residents have had to eat so that they can be sure that a healthy, balanced diet is being offered. Medicine management is much better that at the last inspection, although there is still room for improvement. Movement and handling practice is safer. Staff have had more training about how to safely move and handle residents and are using equipment provided. The general approach of care staff was good; staff have positive relationships with residents. An external lift has been fitted to enable residents with physical disabilities to safely access the home. The stair banister has been raised by five inches to make it safer. There are always enough staff on duty to meet the needs of the residents. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 7 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. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Prospective residents are given the information they need to make an informed decision about where to live most of the time. Adequate assessments are completed prior to residents being admitted to the home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Four residents indicated on the questionnaire provided by CSCI that they had been asked if they wanted to move into the home, and two said they didn’t know. It must be noted that the residents living at Colne House have all been resident at the home for several years. Four residents also indicated that they had been given enough information about the home prior to moving in. One resident stated ‘was a long time ago – don’t remember’ and one indicated that they were not given sufficient information. Records for two residents were examined as part of the site visit to Colne House. Both contained a completed community care assessment. Residents living at this home have done so for many years. There have been no new admissions since the Bridgewood Trust took over the home in 2004. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Residents’ care plans fail to fully meet all their health and welfare needs. Identified risks to residents have not been assessed appropriately. Residents are supported to make decisions. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: As part of the site visit, the inspectors examined individual records of two residents. Very little progress has been made in improving the quality of the individual care plans since the last inspection visit. Those examined were found to contain some inconsistent and conflicting information and it was unclear what information was current and what was historical. The new care planning tool consists of a comprehensive personal support assessment that should then inform the care plan. One of the personal support plan assessments that had been completed contained good, clear information and there was evidence that the resident had been consulted as part of the process. The other assessment however was incomplete, and it was unclear from the way it had been written Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 11 whether the resident had been involved in the process. The resident was unable to clarify this when asked. There was a lack of information about how care should be delivered in both care plans that were looked at. All residents must have a clear care plan that details how individuals’ needs should be met. A requirement has been made in respect of this. Since the last inspection, sit on scales have been purchased to enable staff to monitor the weight of residents unable to use stand on scales, and this is positive. It was noted in the records, however, that there was no consistent monitoring of weight and no instruction to staff within the care plan about how often the residents’ weight should be monitored. This must be included as part of the care plan. It was positive to note that staff have made good progress in maintaining daily records, records of contact with health professionals, family etc and records of food provided. It was noted, however, that changes to residents’ health or care needs identified in contact records had not always been transferred onto the care plan. Further development of risk assessments is necessary. Some identified risks had not been appropriately assessed and therefore no clear guidance to staff about how to minimize risks was available. Movement and handling risk assessments and care plans did not contain sufficient information. As part of discussions with the Residential Services Manager during the site visit, the inspectors were informed that the newly appointed acting manager, currently on induction, would be prioritising the development of individual care plans and risk assessments following completion of her induction period. The inspectors were confident that the acting manager had a good understanding of the care planning process. There was evidence during the site visit that staff are supporting residents to make some choices. A choice of menu is now available and staff were observed to offer a choice of pudding to all residents. As part of the resident questionnaire provided by CSCI, residents were asked if they make decisions about what they do each day. Two residents indicated ‘always’, three indicated ‘usually’ and one ‘sometimes’. When asked ‘can you do what you want during the day, evening and at weekends’, all six residents who responded indicated that they could choose at weekends and in the evening and five indicated that they could choose what to do during the day. One resident said ‘sometimes I want to stay in the garden and not go to work’. It is recommended that this be explored further with the resident and support offered to make appropriate decisions about how to spend their time. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Good opportunities are offered to some residents to access community based leisure and educational activities. Good support is offered to residents to maintain contact with family and friends. Residents’ rights are respected. Residents enjoy the food that is provided. The food is nutritious, healthy and varied. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Five of the eight residents living at Colne House attend day services specifically for people with learning disabilities on a part time basis. Staff reported that the three remaining residents are supported to participate in activities at Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 13 home. Inspectors observed a resident enjoying doing a jigsaw puzzle with support from staff. Records indicated that some residents are receiving support to access the community on a fairly regular basis; a resident confirmed this. Staff reported that a resident whose needs have increased must have two staff available at the home at all times for moving and handling. This is reported to have had an impact on the opportunities for the remaining residents to access community based activities due to availability of staff. The Residential Service Manager informed the inspectors that this situation would be resolved in the near future as a more suitable service had been identified for the resident. Residents are offered good support to maintain links with family and friends. Evidence of this was seen in records and some residents confirmed that they see their families. Staff reported that residents are encouraged to have visitors at the home and are supported to visit friends and family. Feedback received from relatives of two residents confirmed that they could visit their relative in private, were made welcome at the home, were kept informed of important matters affecting their relative and consulted about their relative’s care. Staff were observed to make efforts to promote independence, individual choice and freedom of movement. For example, a resident requiring assistance with meals is offered finger foods some of the time so that independence can be maintained; residents have unrestricted access to most areas of their home. The laundry and office are accessed with staff support. Interaction between staff and residents was more positive than at the previous inspection visit. Staff were observed to include residents in conversations and communicate with residents in a respectful manner. Residents’ preferred form of address has been added to records since the last inspection visit and this is positive. Good progress has been made in improving the choice of meals provided. Staff have begun developing a menu using photographs and pictures to enable all residents to make a choice. Some further development is required in this area, however staff spoken to were enthusiastic about this and discussed how they were going to improve the pictorial menu. A ‘smoothie’ maker has been purchased recently as part of efforts to encourage residents to have the recommended five portions of fruit and vegetables each day. Staff reported that the use of laxative medication has been reduced for some residents since intake of fresh fruit and vegetables has increased. This was noted in resident records. Records of food provided have improved significantly since the last inspection. Where nutrition is a health concern, detailed records of what has been offered and amounts eaten and drunk have been maintained. On the day of inspection, residents had shepherds pie and vegetables for their evening meal and a choice of fruit, yoghurt, mousse or cake for pudding. The meal was well presented and residents said they enjoyed it. When asked about the Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 14 food in general, a resident said that it was ‘alright’. Another resident said that they enjoyed the food. Food was stored appropriately and a good range of fresh fruit and vegetables was available. Menus demonstrate that a balanced and varied diet is offered. There was no evidence at the time of the visit that residents were offered the opportunity to prepare or serve meals and this should be explored, although most residents helped with clearing away afterwards. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents’ health and personal care needs are not always met. Medication is generally managed well by staff, although more care taken in the use and storage of creams would improve practice in this area. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: In order to ensure that residents’ needs are met consistently, more detailed information about how residents prefer to be supported with their personal care and moving and handling needs to be recorded; this was raised at the previous two inspection visits. The acting manager is aware that this area needs further development and will be addressing this as part of her review of the care plans. Staff told the inspectors that they have received further training in moving and handling using the equipment provided at the home. Evidence of this was seen in staff training records submitted with the preinspection questionnaire. Staff said that they always use the appropriate equipment and are no longer lifting manually. The inspectors noted that equipment referred to in a resident’s records was available. Practice in moving and handling was observed to be much improved since the last inspection visit; no unsafe practice was observed on this occasion. Staff were seen to offer Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 16 discreet assistance to residents who needed personal support. A keyworker system is in place at this home although those residents spoken to were unable to say whom their keyworker was. Records examined demonstrated that residents are supported to attend healthcare appointments and referrals are made to appropriate specialists. Records detailing the outcome of healthcare appointments were clear, however due to the layout of the information in resident files, it was not always clear what information was current and what was historical. A resident told the inspector that he had an appointment at the hospital and that staff had explained the reason for the appointment. Residents’ healthcare needs were not adequately described within the care plans and this needs to be addressed. Feedback received by CSCI from a health care professional in respect of the care of residents and how they are received into the home was positive. No concerns have been raised. Medicine management has improved since the last inspection visit. All medicines checked reconciled with records kept. A weekly audit of all medication has been introduced and a procedure for as required or ‘prn’ medication is now in place. The date of changes to a medication regime had been entered on the medication administration sheet (MAR) sheet in one instance but not another. This practice should be implemented consistently. The inspector noted that sachets of a particular medication had been removed from the box that contained the prescription details. Staff were advised at the time to retain the original box with the administration instructions and name of resident for whom the medicine is prescribed. It was noted that creams stored in the bathroom cabinet in a resident’s en-suite bathroom were not prescribed. The manager was not sure if these were used, or to what area they were applied. Records relating to the resident were examined and it was found that creams recommended by health professionals were not available and no reference made to these in the care plan or MAR chart. This needs to be rectified. The inspector advised that a jar of out of date cream be discarded; this was addressed at the time. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has a clear complaints procedure. No complaints have been received since in the past twelve months. Adequate policies and procedures are in place to protect residents from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A satisfactory complaints procedure is in place that is also available in symbol format. The pre-inspection questionnaire states that no complaints have been received by the home in the past twelve months. The inspector was not able to establish whether residents understood the complaints procedure during discussion with them. Four residents indicated on the questionnaire from the CSCI that they knew who to speak to if they were not happy and three said that they knew how to make a complaint. One resident said ‘I wouldn’t say anything’ and one said ‘not sure’ in response to the question ‘do you know who to speak to if you are not happy’. Three residents indicated that they did not know how to make a complaint though one added ‘but I would tell staff and they will help me’. It is recommended that those residents who do not know how to make a complaint be given this information in a way that they can understand. Feedback received from relatives indicated that they were aware of the complaints procedure but had never had to make a complaint. A satisfactory adult protection procedure is in place and some staff have received training in this area. Training in abuse awareness is booked for June 2006 for some staff. A copy of the Kirklees multi-agency guidelines was available in the home. The pre-inspection questionnaire states that no adult Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 18 protection investigations or Protection of Vulnerable Adults (POVA) referrals have been made in the past twelve months. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,30 Residents live in a clean, comfortable home with plenty of communal space. The home is not entirely suitable for residents with physical disabilities. Bathroom facilities at the home need improving. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection visit, the provider and CSCI have met to discuss the proposed development plans for the home. The provider is planning to replace all shared bedrooms with single occupancy rooms and upgrade bathroom and toilet facilities. A small flat on the ground floor used by the previous owner as private living space was in the process of being decorated at the time of the site visit. The Residential Service Manager reported that this was an interim measure for a resident currently accommodated on the first floor whose needs are such that it is now necessary that they be moved downstairs. It is proposed that this area will be adapted for one resident with mobility difficulties as part of the redevelopment of the home. An external lift has been installed since the last inspection that has enabled a resident with physical disabilities to go out with support from staff. The layout and facilities at the home however are not currently suitable for residents with mobility difficulties, Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 20 therefore alternative accommodation has been identified for a resident whose needs have increased in this area. As part of this site visit, communal areas, the ground floor bedroom, en-suite bathroom and first floor bathroom and toilet were seen. The home is comfortably furnished and is domestic in style. Since the last inspection visit, the stair banister has been raised by five inches as a safety precaution. The bathroom facilities at this home are in need of improvement and modernisation. There is a toilet with wash hand basin for residents’ use on the ground floor, and a shower room with toilet and wash hand basin on the first floor. Seven of the 8 residents do not have access to a bath; only a shower is provided. The water temperature of the shower in the first floor bathroom was unacceptably low at the time of the site visit (38°C) and fluctuates when taps are turned on/toilet flushed. The acting manager arranged for maintenance to come to repair the shower during the site visit. Staff do not currently monitor the hot water temperature of the shower and it is recommended that this be done in order to ensure the safety of residents. A second toilet is available on the first floor, however there is no wash hand basin. The bath in the en-suite bathroom is very low and only accessible on one side. There is a large laundry room in the basement of the home. A commercial washing machine and tumble dryer is available. Since the last inspection visit, the domestic employed for fifteen hours per week has left the home. This post is currently vacant. All areas of the home that were seen were clean and free from offensive odour. Four residents indicated on the questionnaire provided by CSCI that the home was always clean and fresh, and two residents indicated that the home was usually clean and fresh; this is positive. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Relevant training is provided to staff although the sixty per cent of staff are not appropriately qualified to NVQ level two or above. Staffing levels are adequate to meet the needs of the residents. Good recruitment practice and procedures are in place. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staff demonstrated that they have the skills and qualities required to meet residents’ needs. Staff were observed to be approachable and comfortable with residents and the atmosphere was relaxed and friendly. Six residents indicated on the questionnaire provided by CSCI that staff always treat them well, and five indicated that carers always listen and act on what they say; one resident indicated that carers usually listen and act on what they say. Staff training records were not up to date, however copies of certificates verified that staff attend a wide range of relevant training. It was noted on the pre-inspection questionnaire that a number of residents have visual and hearing impairments. Staff have not received training in sensory impairment and it is recommended that this be explored. Of ten care staff, four have achieved NVQ level 2 in care. It is recommended that the remaining staff Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 22 continue working towards achieving this qualification. There is a comprehensive training and development plan in place in addition to ongoing NVQ training. New staff complete the Learning Disability Award Framework induction and foundation training. Standard 33 was not assessed in full. However, due to concerns raised at the last inspection that insufficient staff were on duty some of the time, rotas were examined and discussion with the acting manager regarding staffing levels took place. Rotas submitted with the pre-inspection questionnaire suggested that, on most days, there were periods where there was only one member of staff on duty. Due to the mobility needs of a resident, a minimum of two staff must be available at the home at all times. The acting manager assured the inspectors that the rota has been amended and that there is always two staff on duty. Staff spoken to confirmed this. Feedback from relatives indicated that, in the their opinion, there is always sufficient staff on duty at the home. The acting manager explained that staff cover would be more flexible after the resident with mobility difficulties has moved into their new home. Staff recruitment records were examined at the previous inspection visit and were found to be in good order. Staff records submitted as part of the preinspection questionnaire indicates that the home’s recruitment practice continues to be satisfactory. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 A newly appointed manager is running the home. Good quality assurance systems are in place at this home. The health, safety and welfare of residents is protected in most areas. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The registered manager has left Colne House and an acting manager is in place. At the time of the site visit, the acting manager had been in post for a week and was completing her induction. The acting manager has worked in a senior role within another Bridgewood Trust home, although has not been a registered manager before. CSCI have not yet received an application from the acting manager to become the registered manager. Two residents said that they liked the new manager. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 24 The organisation uses the ISO 9000 quality assurance system and a full audit was completed in February 2006. In addition to this formal system, feedback is sought from residents through resident meetings and resident questionnaires are completed prior to individuals’ annual reviews. Completed questionnaires were seen in resident records, however these had not always been signed. Records of residents’ meetings were examined and it was noted that standard agenda items are rights and choices, support, staffing, organisation and ‘any other business’. Meetings take place four times a year. Minutes of the meetings need more detail to ensure it is clear which agenda items have been discussed and what action has been taken. The Residential Services Manager is the appointed person to undertake the monthly provider visits. A copy of his report is submitted to CSCI; these are comprehensive and cover a wide range of areas. The pre-inspection questionnaires indicate that regular safety checks and maintenance of equipment is carried out as required. At the previous inspection visit, it was highlighted that the fire alarm had not been tested at the required interval. The action plan received from the provider following the last inspection states that weekly fire alarm checks are now being conducted. Moving and handling practice has improved since the last inspection visit and this is positive. For the protection of residents and staff, risk assessments and individual care plans must be developed and maintained to ensure that all staff are delivering care as agreed. As previously mentioned, the hot water temperature of the shower should be monitored to ensure that it is close to the recommended temperature of 41°C. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 X X 2 X Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 YA18 YA6 Regulation 15 Requirement The registered person shall prepare a written plan as to how the residents needs in respect of his health and welfare are to be met. 31/10/05 and 28/02/06 unmet. Unnecessary risks to the health or safety of residents are identified, and so far as possible eliminated. 31/10/05 and 28/02/06 unmet. Medication must be stored in the original container. Creams should be recorded and administered in line with instructions from health professionals. Timescale for action 31/07/06 2. YA9 13 31/07/06 3. YA20 13(2) 30/06/06 4. YA27 YA24 23(2)(b)(j) 31/07/06 The provider must provide an action plan indicating timescales for the proposed improvements to bathroom facilities. The provider must arrange for the acting manager or another appointed person to apply to CSCI to be the registered manager. DS0000062797.V296143.R01.S.doc 5. YA37 8(1)(a) 31/07/06 Colne House Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. 3. 4. Refer to Standard YA17 YA9 YA22 YA27 YA32 YA35 Good Practice Recommendations Residents should be offered the opportunity to participate in the preparation and serving of food taking into account individual risk assessments. Staff should ensure that where possible, dependent on residents’ level of understanding, the complaints procedure is explained in an appropriate format/language. The hot water temperature from the shower should be monitored to ensure it is delivered close to forty-one degrees centigrade. A record of this should be kept. Staff should continue working towards achieving NVQ level 2 or above. 50 of care staff should be qualified to NVQ level 2. It is recommended that staff be provided with training in relation to sensory impairment. Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Colne House DS0000062797.V296143.R01.S.doc Version 5.2 Page 29 - 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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