CARE HOMES FOR OLDER PEOPLE
Colne Place 97 High Street Earls Colne Colchester Essex CO6 2RB Lead Inspector
Jane Greaves Unannounced Inspection 12th October 2005 1120 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 Colne Place DS0000017797.V258818.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. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Colne Place Address 97 High Street Earls Colne Colchester Essex CO6 2RB 01787 222314 01787 222314 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) Handsale Limited Mrs Maria Connolly Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th April 2005 Brief Description of the Service: Colne Place is a residential care home for the elderly set in a period residence with large well maintained grounds in a village location. Registered for 33 residents, accommodation is mainly in single rooms many of which have en suite facilities. The home provided 24-hour care for service users with varying levels of dependency and was fully equipped to provide a safe environment for those with restricted mobility. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place 12th October 2005 over a period of 3¼ hrs. 16 of the National Minimum Standards were assessed and 12 were met. For the purpose of this report the people living at Colne Place prefer to be referred to as ‘residents’. The inspector gathered views from 8 residents, 1 visiting district nurse and the staff and management team at the home. The inspector was encouraged to take an independent tour of the premises and experienced excellent cooperation with the inspection process from all staff members on duty. 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.
Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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 Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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): 3 and 5 No resident moved into Colne Place without having their needs assessed and being assured that these would be met. Prospective residents and their families/representatives were encouraged to visit and assess the quality of the facilities and suitability of the home. EVIDENCE: The registered manager was able to demonstrate the robust pre-admission procedures at Colne Place. The registered manager and a senior member of care staff would visit the resident in their own home or in hospital and where possible the prospective resident and their family/representatives would be encouraged to visit the home. A thorough assessment was made of the individual resident’s needs and aspirations covering all aspects of daily life. Once the decision was made to enter the home, either on a trial basis or on a permanent basis, the pre admission assessment was used to develop a plan of care of the individual. Families and representatives were actively encouraged to participate in the process, the registered manager reported that information supplied by families and loved ones was invaluable when developing the plan of care.
Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 9 Residents were offered and encouraged to ‘test drive’ the home before moving in on a permanent basis to ensure that the home was able to meet the individual needs of the resident. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 Residents’ health, personal and social care needs were set out in an individual plan of care. Residents reported they were treated with respect and dignity. EVIDENCE: Three care plans were sampled at this inspection. The plans were drawn up from the pre admission assessment involving the resident and family or representative. The care plans set out in detail the actions needed to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the resident. Risk assessments identifying potential hazards to residents’ safety, resulting infringement of rights notices, photograph of the resident, inventory of personal belongings, details of next of kin, information regarding healthcare interventions required were all present on files together with informative sections such as ‘what I prefer’ and ‘lifestyle and interests’. All residents spoken with at this inspection confirmed they felt respected and their privacy and dignity was protected. Medical examinations were carried out in private, staff members were observed to knock on residents’ doors and announce themselves on entering their rooms.
Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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): 12 and 14 Residents’ experiences within the home matched their expectations and satisfied their cultural, social, religious and recreational interests and needs. Residents were supported to exercise choice and control over their lives. EVIDENCE: There were no visitors to the home on the day of the inspection however, residents’ confirmed that they were able to receive visitors at any time and could spend time with them in the ‘quiet lounge’ or in the privacy of their own rooms. The registered manager and staff team reported how much they valued the input received from families and friends of the residents regarding individuals’ likes and wishes. Regular activities and entertainment was provided for residents at Colne Place. A ‘reminiscence’ afternoon was scheduled where residents could participate in a wartime sing-along and enjoy memorabilia from that era. Residents reported enjoying an ‘exotic animal’ encounter previous to this inspection where they were able to hold spiders, snakes, scorpions and other such exotic creatures. A further session had been booked. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 12 Residents were encouraged to bring personal belongings into the home when they moved in to individualise their personal space, an inventory of these items was present on care plans sampled. Residents were supported to exercise choice over their lives. Bed times and rising times were flexible according to residents’ wishes, choices were available at each mealtime, residents were able to spend time alone in their rooms if they so wished and all residents reported they were consulted regarding all aspects of their daily lives. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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): 16 and 18 Residents could be confident their complaints were listened to, taken seriously and acted upon. Residents could not be assured they were protected from abuse. EVIDENCE: There had been no complaints received by the home or the Commission for Social Care Inspection since the previous inspection. The home had a robust complaints policy and procedure that was subject to annual review. The majority of care staff had undergone training in the Protection of Vulnerable Adults from abuse. The remaining staff members were scheduled to attend training. In discussion the registered manager demonstrated good knowledge of PoVA procedures however one member of care staff had started work at the home before a completed Criminal Record Bureau disclosure had been received. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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): 20, 24 and 26 Residents had access to safe and comfortable indoor and outdoor facilities. Residents’ individual bedrooms were personalised, safe and comfortable. The home appeared clean and hygienic on the day of the inspection. EVIDENCE: Communal spaces of the home were bright, airy and well decorated. There was easy access for wheelchairs throughout the house and attractive wellmaintained gardens. Lighting and furnishing in communal areas was domestic in character and of good quality. Residents’ bedrooms were furnished and equipped to ensure comfort and privacy. As mentioned previously in this report the residents were encouraged to bring their own possessions into the home to personalise their space. In the absence of the residents’ own provision the home supplied appropriate furnishings of good quality.
Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 15 On the day of the inspection the home appeared clean, fresh and hygienic with no offensive odours present. A bathroom on the ground floor and a further facility on the first floor were beginning to look tired and show signs of wear; the registered manager reported that the bathrooms were the next areas for consideration for refurbishment. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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): 28, 29 and 30 Residents could be confident they were in safe hands. Residents could not be assured they were supported and protected by the home’s recruitment practices. The staff team were trained and competent to do their jobs. EVIDENCE: The home was staffed by 24 care staff, 4 senior care staff and the manager. At the point of this inspection 19 staff held NVQ2 level 2 in care, 2 held NVQ 3 and 1 held NVQ level 4. The way in which the staff and management team at Colne Place had embraced NVQ training was commendable. As mentioned previously in this report one member of the care staff team had started to work at the home before the registered manager was in receipt of a satisfactory Criminal Record Bureau disclosure. There was no evidence available at the point of this inspection to confirm if this applicant had been checked against the list of people referred to the PoVA register. The registered manager provided the inspector with the home’s staff training matrix that identified individual and collective training requirements. At the point of the inspection the matrix had not been updated to reflect the true status of training within the home. The record showed that 12 staff members required refresher training in safer people moving handling, just eight of the
Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 17 team had current infection control training, half had received PoVA training and no-one had current competency assessed medication training. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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): 36 and 38 Staff did not receive formal supervision. The health, safety and welfare of residents and staff at Colne Place were promoted and protected. EVIDENCE: Historically the registered manager had a sound system of staff supervision in place but over the past year this had been allowed to lapse. Informal supervision formed part of daily life at the home however the manager was advised of the importance of formal documented supervision sessions. There was an open atmosphere between the staff and management of the home and all parties confirmed they would be comfortable discussing any issue with the manager, whether work related or personal. All necessary health and safety routine checks had taken place and documentation confirmed this. All policies and procedures were subject to
Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 19 annual reviews in order to reflect changes in regulations and practice. Some of the hoists within the home had not received recent servicing; the manager was in the process or organising a servicing contract with a new contractor at the point of this inspection. The health and safety of residents and staff was further protected by the home’s risk management strategies. Assessments of potential risks and appropriate actions to be taken were present on file for areas such as wheelchairs, hoists, ramps, slips and falls, windows, radiators and the laundry. Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X 3 X X X 3 X 3 STAFFING Standard No Score 27 X 28 4 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 x 3 Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 21 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 OP18 And OP29 Regulation 19(1)(b) Requirement The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in Schedule 2. This specifically to completed Criminal Records Bureau disclosures. The registered person must ensure all persons employed to work at the care home receive training appropriate to the work they are to perform. This specifically to training in the control of infection, the protection of vulnerable adults, first aid, manual handling and the safe administration and storage of medicines. The registered person shall ensure that persons working at the care home are appropriately supervised. This specifically refers to resuming documented supervision sessions.
DS0000017797.V258818.R01.S.doc Timescale for action 13/10/05 2 OP30 18(c)(1) 31/01/06 3 OP36 18(2) 31/12/05 Colne Place Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Colne Place DS0000017797.V258818.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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