Inspection on 05/01/06 for Colne Valley

This inspection was carried out on 5th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Colne Valley 08/01/08

Colne Valley 28/06/06

Colne Valley 15/09/05

Colne Valley 21/03/05

Colne Valley 10/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Colne Valley 185 Scar Lane Milnsbridge Huddersfield West Yorkshire HD3 4PZ Lead Inspector Karen Summers Unannounced Inspection 5th January 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Colne Valley DS0000026269.V275430.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. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 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.V275430.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 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.V275430.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at the home on the 5th & 6th January 2006, and the duration of the inspection was 11.5 hours. The manager, Mrs C Horne, and the proprietor, Mrs C Hesp, were present at the inspection, and five service users and a district nurse were also spoken with. The majority of core standards were assessed during the announced inspection in November 2005, which left only 4 standards to be assessed, and 7 recommendations to be followed up from that inspection. A visit to the home was also made on the 21st December 2003, to investigate concerns relating to an alleged restraint of a service user. On that occasion requirements were made in relation to care planning and the need to have access to records that relate to service user, and duty rotas. The records are now available to all staff, and staff are having training on care planning. What the service does well: What has improved since the last inspection? What they could do better: The care records have improved, but they must identify all the care needs of the service user, and how those needs are met on a daily basis. Where the registered provider is not in day-to-day charge of the home he has a legal requirement to prepare a written report on the conduct of the home. A copy of the report should be sent to the Commission and the registered manager. Relatives questionnaires are sent out each year and the results are discussed at residents meetings however, the results should also be published and made available to current and prospective residents. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 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.V275430.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 Colne Valley DS0000026269.V275430.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): EVIDENCE: These standards were not inspected on this occasion. Colne Valley DS0000026269.V275430.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): 7-9 Until the care records include all aspects of the service users care/ needs, and the care plan reflects the outcome of the care delivered, it is not totally clear that the needs of the service user are met. There is evidence of good multi disciplinary working taking place. EVIDENCE: Following the visit in December, the care records of those service users who use a wheelchair to mobilise have the information documented, and all staff have access to service users records. The care records have improved, however they must also include psychological heath and needs/ guidelines on behaviour and confusion where appropriate. The daily records should also be written in greater detail to reflect the care that has been given to the individual service user. Mrs Horne has arranged a date for staff to receive training in care planning. Digital stand on scales have been purchased, unfortunately one of the service users cannot balance for sufficient time for the scales to work. Sit on scales should be purchased when stand on scales cannot be used, or provision cannot be made to monitor the residents weight on a monthly basis. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 10 The owner and manager have also arranged a meeting with relatives/ residents to discuss the implications of having a security lock on the entrance door. Should relatives/ residents agree that the lock remains then the manager plans to record the information and assessments in the service users care plans, and also include the information in the service users guide. A district nurse was visiting at the time of the inspection and she commented that there was a good working relationship between the home and the nurses, and that the home always refers residents to the nurses when they should do, and in the right way. Colne Valley DS0000026269.V275430.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): The standards were not inspected however, the recommendations from the last inspection were. EVIDENCE: As recommended at the last inspection, information is now available to inform residents, relatives and friends on how to contact an advocacy service who will act in their interest. In relation to the kitchen refrigerator/ freezer temperatures, satisfactory records are now been maintained. Service users who were spoken with commented that the staff were all very good, and that the food was always nice. They said that they did not have any grumbles, and if they had any concerns then they knew who to go to. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: These standards were not inspected on this occasion. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 13 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): The standards were not inspected however, the recommendations from the last inspection were. EVIDENCE: Bathroom 9 – a window opening restrictor was fitted, and Bedroom 6 - the damaged window opening restrictor was repaired/ replaced. On the 16th & 17th January work is due to commence in the laundry to ensure that the walls are cleanable and the floor covering is water-resistant. Also during the month of January, Mrs Hesp plans to redecorate the lounges and having new curtains fitted. The proprietor continues to liaise with the Fire prevention officer to ensure that the home meets fire regulatory standards. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 14 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 In relation to NVQ training for carers, residents’ needs are met by appropriately trained staff. Residents are supported and protected by the home’s recruitment practices, EVIDENCE: 21 of care staff have achieved an NVQ level 2 or equivalent, and a further 6 staff are due to complete their training at the end of the month. Making a total of 64 having the qualification. In relation to recruitment, the staff files contained the relevant information and documentation. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 15 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, 33, 35, 36 & 38 The registered manager is of good character and competent to manage the home. Staff are appropriately supervised. The home is run in the best interest of the residents. 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. Residents/ relative questionnaires are sent out each year and the results are discussed at residents meetings. A recommendation is made to publish the results and make them available to current and prospective residents. A relatives meeting is also due to take place later this month, this meeting is intended to keep the relatives up to date with any changes in the home. A Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 16 monthly newsletter is also published and includes items of interest for the residents/ relatives and prospective residents. Where the registered provider is not in day-to-day charge of the home he has a legal requirement to prepare a written report on the conduct of the home. A copy of the report should be sent to the Commission and the registered manager. Service users personal finances were inspected and found to be correct. Mrs Hesp should also keep receipts of any purchases made on behalf of the service user. The supervision of staff takes place approximately every two months, and records are maintained. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 X 3 Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 18 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. 1. Standard OP7OP8 Regulation 14.(2)(b) Requirement Timescale for action 31/01/06 2. OP33 26-(1) (3)(4)abc 5ab “The registered person shall ensure that the assessment of the service user’s needs is – revised at any time when it is necessary to do so having regard to any change of circumstances.” Where the registered provider is 31/01/06 an individual, but not in day to day charge of the care home, he shall visit the care home in accordance with this regulation.” 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. Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 19 2. 3. OP8 OP26 Standard 8.9 – Sit on scales should be purchased when stand on scales cannot be used, or provision cannot be made to monitor the residents weight on a monthly basis. Standard 26.4 - Laundry - The floor finish should be impermeable and wall finishes be cleanable. Work is due to commence 16th & 17th January 2006 to address this recommendation. Standard 28.1 - 50 of care staff should have achieved an NVQ level 2. By the end of January 2006 care staff are due to complete their training, and this will bring the total to 64 of care staff having an NVQ 2. Standard 31.2 - The manager should have an NVQ level 4 in management and care or equivalent. Standard 33.4 – The results of the service users surveys should be published and made available to service users, their representatives and other interested parties. Standard 35 - Receipts should be kept of any purchases made on behalf of the service user. 4. OP28 5. 6. 7. OP31 OP34 OP31 Colne Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 20 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 Valley DS0000026269.V275430.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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