Inspection on 23/10/07 for Coloma Court

This inspection was carried out on 23rd October 2007.

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

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

Other inspections for this house

Coloma Court 05/03/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Coloma Court Layhams Road West Wickham Kent BR4 9QJ Lead Inspector Pauline Lambe Unannounced Inspection 23rd October 2007 09:40 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 Coloma Court DS0000067988.V347483.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 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. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coloma Court Address Layhams Road West Wickham Kent BR4 9QJ 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) 020 8776 1129 020 8776 1927 The Hospital Management Trust Maria Covington Care Home 62 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (52) of places Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th March 2007 Brief Description of the Service: Coloma Court opened in October 2006 and is a modern purpose-built threestorey building set in the grounds of the Daughters of Mary and Joseph’s estate in West Wickham. The registered care provider is The Hospital Management Trust. The home was built to a high specification, in line with regulation and to meet the needs of the people within its registration category. The home was registered to provide care for 52 older people requiring nursing care and 10 requiring dementia-nursing care. All bedrooms are for single occupancy with en-suite facilities and bedrooms and lounges have a view over the landscaped gardens or the countryside. Ample communal and storage space was provided and lounges situated so residents had pleasant views for the windows. Suitable bathing and toilet facilities were provided and fitted and decorated to a high standard. The property had two passenger lifts to enable residents to access all floors. The home is situated close to transport links and local shops and amenities. The current fees for the service ranged from £827 - £879 per week. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors completed the site visit for this unannounced key inspection on 23rd October 2007. The manager was present for part of the inspection and together with senior staff, residents, relatives and staff assisted with the inspection. Sixty residents were in the home, one resident was in hospital and there was one vacancy. The last key inspection for the service was on 5th March 2006. The inspection process included a review of information held on the service file, a tour of the premises, a review of records, talking to residents, staff and obtaining feedback from relatives and residents, assessing the information provided in the registered person’s annual quality assurance assessment, assessing how the service met the key national minimum standards and compliance with previous requirements. The service had a stable staff team and residents and staff had settled into their new environment. Residents and relatives were very satisfied with the care provided and were very complimentary about the overall environment. The staff presented as a cohesive team who worked together to meet the needs of the residents. Some standards assessed required improvement to ensure they met the national minimum standards. What the service does well: What has improved since the last inspection? Resident care plans were regularly reviewed. Night staff attended regular fire drills. Satisfactory systems were in place to record complaints. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 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 Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 4. Standard 6 did not apply to the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information about the home and how it operates was provided to enable people to make informed decisions about the service. Residents were admitted to the service based on a pre-admission assessment but did not receive written confirmation that the service was suited to meeting their assessed needs. EVIDENCE: A statement of purpose and very informative information pack was provided. The statement of purpose complied with regulation but could include more detail in relation to the criteria for admission to the home. The service user guide was seen in some resident’s bedrooms. Recommendation 1. Four sets of care records were viewed and showed that residents were admitted to the home based on completion of a pre-admission assessment. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 9 Some of the residents spoken with said they had enough information about the home and had visited prior to admission Although the service had a standard letter to give to residents confirming the service could meet their assessed needs this was not evident in the care records seen. Requirement 1. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were prepared but some areas required improvement. Systems were in place to ensure resident’s healthcare needs were met. Medicine management required some improvements. Residents were satisfied with the way staff respected their privacy. EVIDENCE: Inspectors spent time on the ground and second floor units. Care records were viewed for six residents. Staff were in the process of changing from written to computer held records. It was therefore necessary to view two sets of records to get the full picture. Care must be taken during this transition period to ensure relevant information is available to staff on duty especially as not all staff currently access the computer. On the ground floor one record viewed was for a resident admitted the day before the inspection, staff had already begun to draw up a basic care plan in relation to the person’s health, personal care, and mobility. Other records were up to date and showed how assessed needs were to be met. One record seen showed that the resident had been reviewed by a Consultant Psychiatrist in August 07 who had had Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 11 made recommendations regarding suitable activities, however there was no evidence to show that staff had acted on the advice given. It was evident from records seen and from the behaviour displayed by the resident that there were times when the resident’s behaviour was difficult for staff to manage. There was no evidence to show that this issue had been addressed and staff were advised to seek additional professional advice regarding behaviour management. There was evidence in some of the records seen that residents were involved with preparing them. On the second floor care records seen included assessments and care plans to show how assessed needs were to be met. However care plans seen in relation to wound care required improvement. The record seen for one resident did not clearly show the frequency of dressing renewal or the condition of the wound. Care plans were reviewed regularly. Care assistants spoken with said they did take time to read care plans. Residents and relatives spoken with were satisfied with the care provided. Requirement 2. All residents were registered with a GP and many with the GP they had prior to admission. Staff said they had good working relationships with the GP and community nursing service. Staff supported residents to access other healthcare such as optician, dentist and chiropody. Records seen showed that staff accessed additional healthcare support when needed such as advice from psychiatric nurses, dietician and tissue viability nurse. A visiting psychiatric nurse spoken with said that staff used their service appropriately and followed advice given for the benefit of residents. During a tour of the home it was evident residents were provided with pressure relief equipment. Residents spoken with said they could see the GP and other healthcare professionals when needed. Medicine management was inspected on the second floor. A policy and procedure was provided for staff. The unit had satisfactory storage facilities, a medicine storage fridge, a medicine trolley to administer medicines and hand washing facilities. Records were kept for receipt, administration and disposal of medicines. Medicines were mostly supplied in blister packs, with pre-printed administration charts and on a 4 weekly cycle. A list of staff signatures was seen. Staff had started completing medicine profiles for residents on the new computer system. Administration charts seen showed that hand written entries made by staff were not signed or counter signed and staff had changed one medicine instruction from ‘to give 4 times a day’ to give ‘PRN’ (when required). Medicines were checked for three residents. Records and remaining supplies for one resident was correct but and the second record showed an error for one medication i.e there were too many doses in stock compared with the number supplied and administered. The record for a third resident showed an error in one medicine and the remaining supply of a second medicine for the resident contained the same medicine but in two different types of packaging. This may have occurred if staff transferred left over medicines from the previous stock to the new container. There was no stock of homely remedies in the home. Some staff said they used homely remedies and other Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 12 staff said they didn’t. The policy and procedure for the service included a list of homely remedies but this had not been signed and agreed by the GP. Staff spoken with said they received in-house training on medicine management. On the ground floor the medicine records for three residents were viewed. These were satisfactory but staff had not signed or counter signed hand written entries they had made on the administration charts. The inspector saw one loose tablet and when this was brought to the attention of staff the person dismissed it as ‘just a calcium table’ and threw it in the bin. This issue was brought to the attention of the manager. Requirement 3 and recommendation 2. Residents and relatives seen and those who provided written feedback were complimentary about staff and how staff resident’s privacy. All bedrooms were for single occupancy and had en-suite facilities, staff knocked on doors before entering rooms, some residents had keys to their rooms and bathroom and toilet doors had locks fitted. All of the residents seen were appropriately dressed in clean well-laundered clothing. A hairdresser visited weekly and a resident said they enjoyed having their hair done as it made me feel better. Staff were seen to support residents requiring help with personal care in a calm unrushed manner that respected their privacy and dignity. One resident spoken with stated that staff were caring and couldnt do enough for you. One member of staff said that in their opinion residents were very well respected in this home compared with experiences they had when working in other care settings. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were provided with a range of activities, were supported to maintain contact with family and friends and to make decisions about their lifestyle. A varied menu was provided and residents were mainly satisfied with the food provided. EVIDENCE: There was little evidence on care plans that staff had recorded information regarding resident’s hobbies and interests as part of the assessment process. There was no evidence on resident care plans to indicate their participation in activities. This information was held centrally and the record maintained by the activity coordinator who was on leave during this inspection. Whilst it was evident from the records seen that a range of activities were provided on a regular basis, the recording system did not show whether residents had enjoyed them or not. This information would be particularly useful when caring for people with dementia. Individual social care plans were not prepared. Feedback from residents and relatives varied in relation to activities. Some felt these were adequate and some felt there was a lack of stimulation. Some residents said they did not like to join in organised Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 14 activities and there was evidence to show that residents had one to one sessions such as manicures or shopping trips. Three resident survey forms were returned to the Commission and two showed satisfaction with activities provided. Some staff felt the gardens were not well used by residents and that this was an area that could be improved. A monthly newsletter was provided for residents and included information such as planned entertainment, hairdressing service, resident and staff birthdays for the month, quizzes and lots of other relevant topics suited to the residents. Recommendation 3. The service had an open visiting policy. Relatives seen said they were always made feel welcome, were kept informed about their relative’s well being and could have a meal with their relative if they wished. A resident spoken with stated that visitors were able to come at any time. Staff said that visitors were welcome and could use the kitchen areas on the units to prepare refreshments for themselves. Most bedrooms had private phones fitted to enable residents to maintain contact with family and friends. It was not evident from the care plans seen how resident choice was encouraged. However residents spoken with said staff did ask their opinion and listened to them. For example in relation to what to wear, what time to get up, whether to have a bath, to choose a meal and to if they wanted to join in the organised activities. Residents presented as relaxed and comfortable in the home and many commented on the beautiful views they had from bedrooms and lounges and their environment. Staff were observed talking to residents and helping them make personal choices throughout the day. Food was prepared and plated up in the main kitchen and brought to the units in a heated trolley. This meant that care staff were unable to vary portion size according to residents preferences or easily provide residents with an additional helping. Also residents did not benefit from the sight, sounds and smell of food all of which would help prompt the memory particularly for people with dementia. On the ground floor dementia unit whilst residents were sitting at the dinning tables waiting for lunch, the nurse in charge was asking them to choose their lunch for the following day, which was inappropriate and may well confuse people further. Residents were provided with a choice of two options at mealtimes however it is evident that alternatives were provided if residents did not like the options on the menu. Both the care staff and the chef thought it was the others responsibility to record when residents had been provided with an alternative meal to that shown on the menu and therefore this information was not currently being recorded. A choice of refreshments was provided with lunch and tables were appropriately set including condiments. Menus were prepared on a four weekly cycle and showed a varied diet was provided. Residents spoken with during lunch said that the meal was nice and others displayed this by eating the meal. Staff offered assistance where needed and residents had access to special crockery and cutlery to enable them to remain independent. In addition to main meals it was Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 15 apparent that food was provided dependent on residents needs and wishes. For example one resident was seen having tea and toast late morning and another was provided with fresh fruit prepared by staff. Residents nutritional needs were assessed using the ‘MUST’ assessment however staff on the ground floor were not using this and were not aware of it. Resident’s weighed was monitored monthly and where needed referrals were made to the GP or dietician for advice. Recommendation 4. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory systems were in place to manage complaints and safeguard residents. EVIDENCE: A complaints policy and procedure was provided and a copy included in the information pack provided. Records were kept of complaints made about the service. Since the last inspection three complaints had been made and records seen showed these had been managed appropriately. No complaints had been made to the Commission. Residents and relatives spoken with said they knew how to make a complaint and who to talk to if they had a concern. A policy and procedure was in place relevant to safeguarding adults. The manager was aware of her responsibility to report allegations or concerns of abuse to the local authority and relevant agencies. Staff spoken with displayed a good understanding of safeguarding people and their responsibility to report any concerns to the manager or senior on duty. Staff were also aware of the service’s whistle blowing policy. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained and provided a pleasant and comfortable living space for residents. Bathing and toilet facilities were well fitted and suitable to meeting resident needs. Residents were very satisfied with the environment and particularly with their private space. EVIDENCE: The home was purpose built and opened in 2006. The building was being monitored for settlement cracks and other snagging issues, which would be addressed. The home was well designed with light airy rooms and lovely views from all bedrooms and lounges. Furnishings and fittings were to a high standard and the premises were clean, tidy and odour free. A maintenance technician was employed and ensured minor repairs, health and safety issues and routine safety checks were completed. A gardener was employed to maintain the lovely landscaped gardens. Residents and relatives spoken with were very pleased with the environment and the standard of cleanliness in the Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 18 home. The home is situated in a semi rule location and all of the residents spoken with stated how much they enjoyed being able to look out over the surrounding fields. Adequate and suitable bathing and toilet facilities were provided and assisted bathrooms had ceiling hoists fitted. Bathrooms, shower rooms and toilets were spacious, well fitted and decorated to a high specification and to look homely. Not all of the bathing facilities had signs on the door to assist residents to recognise various rooms. Requirement 4. Resident’s bedrooms seen were nicely personalised with photos and mementos. A number of wardrobes seen in resident’s bedrooms were found to be unstable and considered a potentially hazard to residents and others. All of the residents spoken with said they were very happy with the accommodation provided. Not all bedroom doors in the dementia unit were signed so that the occupant could easily identify their room. For example the bedroom for a resident admitted the previous day to the unit had the names of the persons key workers but not the name of the resident. Requirement 4. All areas of the home seen were clean and tidy. The laundry was not viewed on this occasion however there were ample supplies of clean linen seen in the units visited and residents personal clothing was nicely laundered and neatly stored. Sluice facilities were provided on all floors and staff had access to appropriate hand washing facilities and adequate supplies of protective clothing. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team had the skills needed to meet the needs of the residents. Staff received training relevant to their work and recruitment procedures were satisfactory. EVIDENCE: The staff team comprised of a full time manager, unit managers, registered nurses, care assistants, domestic and ancillary staff. Staffing levels were based on resident dependency and staff rosters seen showed that good staffing levels were maintained. Some improvements were needed to staff rosters as currently there was more than one record kept. Copies of the worked roster must be kept, must include all staff on duty at all times, including the home manager and must include the full names and designation of staff. Staff said that there was a half hour handover period between the senior members of staff in charge of each shift. Staff also said that there was sufficient numbers of staff on duty to meet the needs of residents. Residents and relatives spoken with were complimentary about staff and comments made included “staff are marvellous” and “overall the care in the home is superb”. Staff spoken with said they felt supported by management. Requirement 5. From the information supplied by the provider 48 care assistants were employed and 41 had achieved NVQ level 2 or above and 4 staff were working towards this qualification. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 20 A sample of staff files including one volunteer, two care assistants and two nurses were examined in relation to recruitment and training. Records seen included completed application forms, proof of identity, two references, CRB and checks and confirmation that nurses were registered with the Nursing Midwifery Council. One file did not have a recent photograph of the employee. Records seen showed that during the interview process staff were assessed in relation to their understanding of safeguarding adults and staff received job descriptions and a contract of employment. The registered person should consider renewing staff CRB checks 3 yearly as good practice. Requirement 6. There were some copies of staff training certificates on the files seen, however staff assisting with the inspection felt this was not a true reflection of the training provided. The team leader spoken with said that staff did not always bring in training certificates and this will be addressed to update files. Discussion took place regarding the need to develop a staff training matrix to monitor staff member’s future training needs. Staff spoken with said they were provided with comprehensive training opportunities and that in addition to statutory training such as manual handling, food hygiene and health and safety they had received additional training such as in relation to caring for people with dementia and diabetes. Recommendation 5. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service had a stable management team and some quality assurance systems were in place. Satisfactory procedures were in place to manager resident’s personal allowances. Staff did not receive formal supervision and some concerns were noted in relation to safety. EVIDENCE: The service was generally well managed and the manager had the skills, experience and support needed to fulfil her role. The manager was registered with the Commission and achieved NVQ level 4 in management. Staff, residents and relatives spoken with said the manager was approachable and regularly spent time on the units. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 22 Records seen indicated that systems were in place to obtain the views of the residents and their advocates about the service. Regular meetings were held with staff, residents and relatives and minutes from these were seen. A discussion took place with management regarding the need for meeting minutes to indicate that feedback was given on the action taken to address issues raised at previous meetings. The trust sent satisfaction surveys to residents and their advocates on a regular basis. Records were seen for internal audits on key performance indicators for areas such as food, laundry and infection control. There was no evidence to indicate that a system was in place to review and improve the nursing care and service provided. There was no evidence to show that internal audits had been completed in relation to medicine management or care planning. Reports were sent to the Commission in line with regulation 26. Requirement 7. Policies and procedures were provided in relation to management of finance and valuables for residents. Satisfactory arrangements were in place to help residents manage their personal allowances if this was needed. Many of the residents relied on family and friends to provide this support for them. An individual record was kept for each resident and receipts kept for money received and spent. Relatives, friends, solicitors and others provided money for residents and this was held as cash in the home. Records for three residents were checked and found to be correct. Staff spoken with said that all of the residents had access to personal money. A requirement was made at the time of the last inspection in relation to staff supervision. There was no evidence on staff records seen to show that action had been taken to address this requirement. Senior staff spoken with confirmed that a system was not in place to provide regular staff supervision however staff had received training in preparation for supervising staff. Staff spoken with said they received informal supervision and were able to discuss concerns or issues they had with senior staff and management at any time. Requirement 8. Safety records seen were up to date. Records viewed included fire safety, lift service, hoisting and bathing equipment service, gas and electricity. A full time maintenance technician was employed and carried out routine repairs and safety checks. Although a system was in place to check hot water temperatures monthly records seen did not include the temperature but were ‘ticked’ to show they had been checked. There was no system in place to assess residents for the use of bedrails or to regularly check bedrail fitting and wheelchairs in use. A number of bedrails seen were not high enough to ensure the resident’s safety particularly when the bed had a pressure relief mattress. Accident records were viewed and were quite confusing. One form was used to record a number of issues such as accidents, incidents and complaints. People completing the forms did not always highlight the issue being recorded. The records did not show the follow up action taken in relation to accidents sustained by residents when they were receiving care or were unexplained. It Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 23 was also noted that two residents had accidents when being helped to transfer by agency staff. These residents did not sustain injuries however this raised a concern about induction and supervision of agency staff working in the home. These issues were bought to the attention of the manager. Requirement 9 and recommendation 6. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 24 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 17 18 3 X 3 X X 2 X 4 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 2 3 X 3 Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The registered person must ensure residents receive written confirmation that based on assessment the service is suited to meeting their assessed needs. The registered person must ensure: • That care plans contain clear guidance on wound management and a record is kept to show the current condition of the wound. • That staff implement the advice provided by health professionals in relation to resident’s specific care needs. The registered person must ensure medicines are safely managed: • Two signatures must support hand written entries made by staff on administration charts. • Records must be kept for administration or disposal of all medicines. • Staff must not transfer medicines from the original dispensed container to DS0000067988.V347483.R01.S.doc Timescale for action 04/12/07 2 OP7 15 27/11/07 3 OP9 13 27/11/07 Coloma Court Version 5.2 Page 26 4 OP19 23 5 OP27 17 6 OP29 19 7 OP33 24 8 OP36 18 9 OP38 13 another. Staff must not change medicine instructions without the consent of the GP. The registered person must ensure: • The wardrobes in resident’s bedrooms are secured. • That appropriate signage is provided to help residents identify areas of the home such as bathing, toilet, ensuite facilities and their bedrooms. The registered person must ensure staff rosters are kept in line with regulation and include full names and designation of all staff on duty. The registered person must ensure the recruitment information required by regulation is obtained for all staff including a recent photograph. The registered person must ensure the quality assurance system includes reviewing all aspects of the service including care provision and medication management. A copy of any review report prepared must be sent to the Commission. The registered person must ensure that persons working at the home are appropriately supervised. (Timescale of 15/04/07 was not met). The registered person must ensure: • A risk assessment is completed prior to fitting bedrails and bedrails provided must be of an adequate height to ensure the resident’s safety. • A system must be in place • DS0000067988.V347483.R01.S.doc 04/12/07 04/12/07 04/12/07 04/12/07 04/12/07 27/11/07 Coloma Court Version 5.2 Page 27 • • • to check bedrail fitting and wheelchairs is use. Accident records must be fully completed and include all relevant information about the incident. A system must be in place to follow up accidents to residents when receiving care and the action taken to prevent a recurrence. Management must ensure new agency staff working in the home are supervised particularly in relation to using moving & handling equipment. 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 Refer to Standard OP1 OP9 Good Practice Recommendations The registered person should ensure the statement of purpose includes adequate information about the criteria for admission to the home. The registered person should clarify the situation regarding the use of use of homely remedies for the benefit of staff. A system should be in place to assess the competency of staff to manage medicines annually and evidence kept of this process. A protocol should be developed for the administration of ‘as required’ medicines for residents who cannot express this need. The registered person should ensure individual social care plans are prepared with residents and activity records kept include a comment as to how the resident enjoyed the session. The registered person should ensure staff have the ability to offer extra food helpings to residents if needed. Staff should not ask residents at mealtimes what they DS0000067988.V347483.R01.S.doc Version 5.2 Page 28 3 OP12 4 OP15 Coloma Court 5 6 OP30 OP38 want for the next day. This can be confusing for residents particularly those with dementia or confusion. Staff should record on the menu choice list when a resident has an alternative meal, which was not on the menu. The registered person should ensure a system is in place to monitor staff training and ensure mandatory training is kept up to date. The registered person should ensure accurate and complete records are kept of hot water temperatures checked. Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Coloma Court DS0000067988.V347483.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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