CARE HOMES FOR OLDER PEOPLE
Colne Valley 185 Scar Lane Milnsbridge Huddersfield West Yorkshire HD3 4PZ Lead Inspector
Karen Summers Announced Inspection 15th September 2005 09:00 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 Valley DS0000026269.V251743.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 Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Colne Valley Address 185 Scar Lane Milnsbridge Huddersfield West Yorkshire HD3 4PZ 01484 659176 01484 659176 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) Mrs Cynthia Hesp Mrs Catherine L Horne Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st March 2005 Brief Description of the Service: Colne Valley care home provides care and accommodation for up to twenty older people with a range of needs. The accommodation is spacious and all but one room has private en-suite toilet and hand basins. The home has some flexibility within its routines, for example meal times, particularly breakfast. Although the home does not provide nursing care the community nursing team are involved with service users at the home, as are other primary care services. The home is located close to the centre of Milnsbridge in the Colne Valley, approximately three miles from Huddersfield, and there is access to local services, including public transport. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report refers to an announced inspection at Colne Valley on Thursday 15th September 2005, commencing at 9am. The duration of the inspection was 5.5 hours. The manager, Mrs C Horne was present at the inspection. The following methods have been used in the production of this report: sampling of records, care plans, individual discussion with 4 service users, tour of the premises and document reading. What the service does well: What has improved since the last inspection? What they could do better:
In relation to the care documentation, the daily record should be written in more detail to reflect the care the service user has received. The service users and their relatives/ friends should be informed of how to contact external agents e.g. advocates who will act in their interest. The refrigerator/ freezer temperatures should be recorded on a daily basis to ensure that the food in these appliances is been stored at the correct temperature. In reference to the environment, windows above ground floor level should not open more that 10cm, and the damaged restrictor in one of the bedrooms should be replaced. The laundry floor covering should be sealed and the walls should be cleanable. 50 of care staff should have achieved an NVQ level 2, or equivalent by 31st December 2005, and the manager should have an NVQ level 4 in management and care. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 6 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 Valley DS0000026269.V251743.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 Valley DS0000026269.V251743.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): 1&3 Prospective service users have the information they need to make an informed choice about where to live, and no service user moves into the home without having had his/ her needs assessed and been assured that those needs will be met. EVIDENCE: The statement of purpose and service users guide contains the information the service user needs to make an informed choice about where to live. Mrs Horne visits prospective service user in their place of residence and carries out an assessment of their needs. When carrying out the assessment the service user and where appropriate, his/ her representative (if any) and relevant health professionals have input into the assessment. Once the manager is satisfied that they can meet the service users needs they are offered a place at the home. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 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): 7, 8 & 10 Until the daily record reflects the outcome of the care delivered it is not totally clear that the needs of the service user are met. Service users are treated with respect and their right to privacy is maintained. EVIDENCE: Staff are in the process of updating the care documentation, which is comprehensive and includes all areas of health, personal and social care. The daily record needs to be written in more detail to reflect the care the service user has received. Two of the service users who were spoken with said that the staff were kind, and that they were well cared for. Staff were also seen to be attending service users in a kind and respectful manner. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 The lifestyle the service users receive match their expectations and preferences. A variety of meals are offered that take into account the likes and dislikes of the service users. Unless the refrigerator/ freezer temperatures are monitored daily service users could be potentially at risk of food poisoning. EVIDENCE: A dedicated activities person has recently been appointed and she works one day a week. The carers also organise activities on a daily basis. Events and activities that have taken place are recorded in a file, and the activities that individual service users are involved in are recorded in their care records. The manager has recently introduced a monthly newsletter, which keeps the service users and their visitors up to date with events at the home. The menus offered a variety of food, and the food preferences and diets were also taken into consideration. A service user commented on how good the food was, and that they had no grumbles. The refrigerator/ freezer temperatures should be recorded on a daily basis to ensure that the food in these appliances is been stored at the correct temperature. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Service users and their relatives can be confident that their complaints will be listened to, taken seriously and acted upon in a timely manner. Service users are protected from abuse. EVIDENCE: There is a complaints procedure which specifies how complaints may be made, and with an assurance that they will be responded to within a maximum of 28 days. There is a whistle blowing procedure, and staff receive abuse awareness training. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 The home is decorated to a good standard, and service users’ individual needs Are met in a comfortable way. Without the appropriate window restrictors in place service users could potentially be at risk. In the laundry area, due to the type of floor and wall coverings they cannot be appropriately cleaned and therefore infection control measures are compromised. EVIDENCE: Generally the home is in a good state of repair and decorative condition. Service users are encouraged to bring small items of furniture and memorabilia into the home, and a number of bedrooms had been individualised with belongings. Bedroom 6 – the window restrictor was damaged and should be repaired/ replaced, and bathroom 9 should have a window restrictor fitted to the window. All radiators in service users rooms have had radiator guards fitted. In the interest of the prevention of infection, the laundry floor covering should be sealed and the walls should be cleanable. The proprietor is working with the Fire prevention officer to ensure that the home meets fire regulatory standards.
Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 The staffing levels and skill mix were sufficient to meet the number and needs of service users. Staff are also trained and competent to do their jobs. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. 23 of care staff have achieved an NVQ level 2 or equivalent, and a further 7 staff have commenced the training. The manager plans to meet the recommended standard of 50 of staff having the qualification by the end of December 2005. There is a staff training and development programme, and the manager confirmed that the programme meets the National Training development organisation (NTO) workforce training targets. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 & 38 The registered manager is of good character and competent to manage the home. EVIDENCE: Cathy Horne, the manager, has many year experience in the care of older people, and she has commenced an NVQ level 4 in management and care, which she plans to complete early next year. 29 questionnaires were received from service users and their visitors/ relatives, and they were positive about the care the service users receive. The supervision of staff has commenced, and takes place approximately every two months. Staff have attended fire lectures and drills, and the emergency lighting and alarm tests are carried out weekly. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 3 2 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 3 X 3 Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Standard 7 - When the outcome of care has not been identified in the care plan, the daily record should be written in more detail to reflect the care the service user has received. Standard 14.3 - Service users and their relatives and friends should be informed of how to contact external agents e.g. advocates, who will act in their interest. Standard 15 - Kitchen – The refrigerator/ freezer temperatures should be recorded on a daily basis. Standard 19.1 - Bedroom 6 – the damaged window restrictor should be replaced. Bedroom 9, en-suite bathroom – should have a window restrictor fitted. (The window should not open more than 10cm.) Standard 26.4 - Laundry - The floor finish should be impermeable and wall finishes be cleanable. Standard 28.1 - 50 of care staff should have achieved an
DS0000026269.V251743.R01.S.doc Version 5.0 Page 17 2 3 4 OP14 OP15 OP19 5 6 OP26 OP28 Colne Valley 7 OP31 NVQ level 2, or equivalent by 31st December 2005. Standard 31.2 - The manager should have an NVQ level 4 in management and care or equivalent. Colne Valley DS0000026269.V251743.R01.S.doc Version 5.0 Page 18 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
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