Inspection on 05/03/07 for Coloma Court

This inspection was carried out on 5th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Coloma Court 23/10/07

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 Layhans Road West Wickham Kent BR4 9QJ Lead Inspector Cheryl Carter Unannounced Inspection 5th March 2007 10:00 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 Coloma Court DS0000067988.V328031.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.V328031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coloma Court Address Layhans 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.V328031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 62 men and women. 10 residents with Dementia 5 residents with Terminal Illness Date of last inspection 1st inspection Brief Description of the Service: Coloma Court is a purpose-built two-storey home providing care for older people. The upper floor is accessed via a lift. The home is generally well maintained and each resident has his or her own room, which is centrally heated. Coloma Court provides care for 62 service users. The Home opened in October 2006, providing nursing and residential care. The home is situated within the grounds of the Daughters of Mary and Joseph’s estate in West Wickham, in an open area overlooking fields and set within private landscaped gardens. Coloma Court has been built to incorporate the most up-to-date features and expectations for long-term care of the elderly. The home is situated close to transport links and local shops and amenities. There are grab and hand rails on stairs and passageways. Toilets, showers and bathrooms have specialised bathing, toilet equipment and lifting aids. All toilets, showers, bathrooms and bedrooms are accessible from the outside in case of emergency. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key unannounced inspection over a period of one day. The Care Manager Mrs Maria Covington assisted the inspector throughout the inspection. The key Minimum Standards for Older people were identified for the inspection and the methods in which the information gained for this report included case tracking, general observations, document reading, speaking with staff, relatives and service users. A tour of the building was also undertaken. At the end of the inspection feedback was given to the manager outlining the overall findings of the inspection, and the recommendations/requirements made. Service users spoken with were positive about the care they were receiving. They are very pleased with the environment. Even those who were unable to communicate appeared well cared for and were happy with their surroundings. Comment cards received from relatives were generally complementary of the service, however one relative complained that it took longer for staff to respond to the phone calls and answer the door in the evenings and weekends. What the service does well: What has improved since the last inspection? Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 6 This is a newly built home replacing the old home Wickham Court Nursing Home. There are 62 single rooms all with e-suite WC and washbasins facilities. Some rooms have shower facilities in the en-suite bathroom. 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.V328031.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.V328031.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): 1, 2, 3, 4, 5, 6 Quality in this outcome area is good. People who use the service can be assured that essential information about the home and how it operates is in place in order for them to make informed decisions about its services. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose and Service User Guide were seen and meet the criteria laid down in the regulations. Prospective service users and their relatives are invited to look around the home prior to making a decision. Relatives and their representatives are invited to be involved in the preadmission assessments if they wish to ensure that the individual needs are identified, to discuss the e plan of care and the documentation that they are asked to agree and sign. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 9 Following a full pre admission assessment each service user is given a letter and contract stating that their needs could be met in the home. The home does not provide intermediate care. Coloma Court DS0000067988.V328031.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): 7, 8, 9, 10, 11 Quality in this outcome area is adequate. The standard of record keeping in the files was not of a high enough standard to ensure that residents could be provided with a consistent service. This judgement has been made using available evidence general observation and discussions with staff, residents and a visit to this service. EVIDENCE: A sample of 4 care plans was undertaken. The recording of information on files was inconsistent. Activity sheets on the files were not filled in. Care Plans and risk assessments were in place but these could be improved. The inspector recommends that a system be put in place to ensure consistency of information on each service user case notes. (Requirement 1) Case records seen evidenced that service users health and personal care needs were constantly being identified and subsequently being met. Care plans contained medical histories but not all care plans seen had a social history. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 11 Access to multi-disciplinary professional including medical consultants and clinical nurse specialists can be accessed when required and these events are recorded. Residents are protected by the home’s policies and procedures for dealing with medicines. Currently there are no residents who are able to self medicate. Medication Administration sheets were completed in line with requirements. Staff interacted with service users in a respectful and friendly manner. The environment was relaxed and informal. Residents were well groomed. Arrangements in the event of terminal illness or death are agreed and recorded. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15 Quality in this outcome area is good. The lifestyle provided by the home is meeting the needs of the service users and contact with family is actively encouraged. The menu reflects the choices and/or assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a full time activity coordinator who is responsible for organising the activities in the unit. During the visit to the home several service users were engaging in activities with the activity co-ordinator. Contact with families is encouraged. On the day of the inspection there was only one visitor to the unit and the inspector was able to speak with the visitor. The visitor explained that she was very satisfied with the care provided by the home. One service user said that her only complaint was that there was not enough tomato soup. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 13 Service users are asked each day for their choice on the menu. There is always an alternative to the main meals. Service users said that the food is good. Dietary needs are catered for. Meals are prepared from a well-run kitchen. This is a newly built home and the kitchen is spacious. The chef’s knowledge of individual residents requirements was extensive and daily menus are offered to residents each morning so that the kitchen can prepare a good choice of meals and alternatives. There is a daily delivery of fresh meat, vegetables, bread, milk and yoghurt. Service users are offered snacks and drinks at regular intervals throughout the day. Cultural and health needs are catered fir as required. Comment cards received from relatives were generally complementary of the service, however one relative complained that it took longer for staff to respond to the phone calls and answer the door in the evenings and weekends. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 14 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): 16, 17, 18 Quality in this outcome area is good The home has a complaints procedure in place however residents cannot always be confident that their complaints will be dealt with as not all complaints are being recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy. There is a system in place for the recording of complaints, however, there was evidence that not all complaints are being recorded. The registered manager must ensure that all complaints are recorded with actions and outcomes. (Rec.1). The legal rights of service users are respected and staff is appropriately trained to ensure residents are protected from all types of abuse. Staff spoken with was aware of their right to express their grievances and of the whistle-blowing procedures. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. The residents can be assured that they live in a well maintained, hygienic and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is a newly built home that opened in October 2006. there are 62 single room all with en-suite WC and washbasin facilities. Some rooms also have shower facilities. Each room has a lockable facility for items of value to the service user. Bedrooms were nicely personalised and safely arranged. Specialist equipment is provided for the residents and serviced regularly to ensure safety. All bathrooms have ceiling hoists and there is also a hydrotherapy bath and Parker Bath. There is sufficient storage space for hoists and wheelchairs and this reduces the risks of tripping. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 16 Fridge and freezers temperatures are recorded daily. The home has had a recent inspection by Environmental Health this was satisfactory and the home is awaiting their Certificate. There is very limited food in stock as all food is bought on a monthly basis. And there are daily supplies of Milk, bread, fruit, and yoghurt. Emergency lighting, and water temperatures are all regularly tested and results recorded. Laundry facilities were to the standard required for good working conditions. The ancillary staff was working hard to ensure the environment is maintained to a high standard. Staff spoken to had knowledge of COSSH requirements relating to the cleaning and the Laundry. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29, 30 Quality in this outcome area is good. Residents can be assured that they are safe and their needs can be met by a staff group who are trained and competent. This judgement has been made using available evidence EVIDENCE: As part of the visit to this service an examination of staff rotas, training and supervision records and discussions with the Manager and Care Staff was undertaken. Staffing levels are based on the dependency. Ground floor - 10 beds - one nurse and two care staff on each shift. 1st floor - 26 beds – one nurse and seven care staff on each shift. 2nd floor 26 beds – one nurse and seven care staff on each shift. All carers carry bleeps. Discussions with all staff was very positive, all felt valued and all felt that they belong and committed to the team and to the philosophy of the home. The Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 18 care manager is fully supernumerary which enables her to complete her managerial tasks. There is also a full time activity coordinator. The home also has a receptionist and an administrator and someone responsible for maintenance. Adequate domestic and Laundry staff is provided throughout the week and weekend. The home has robust recruitment policies and procedures. Staff files that were inspected had been subject to POVA/CRB comprehensive checks, and these were recorded. All necessary processes had been followed and were evidence. The home has a training schedule for the staff, however the inspector did not see the individual training records for each staff on their files. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. People who use the service can be satisfied that the home is generally managed well, however to maintain this the manager will need to ensure that formal supervision of staff is increased and all staff are involved in fire drills. This judgement has been made using available evidence. EVIDENCE: The home is well run by a manager with good leadership skills an supported by a professional team of nurses and experienced care staff. The manager has completed her Level 4 NVQ management-training course. Several care staff is first-aid trained in the home and food hygiene training and updates are continuous. Accident and incident recording was completed in line with requirements Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 20 Care staff spoken with and records seen indicated that supervision for staff is not currently meeting the required standard. The registered manager must ensure that all staff are receiving supervision. (Req. 2) Health and safety checks of equipment and systems within the home were evidenced to be in order. Fire safety training was in order, however it was unclear how night staff training is undertaken with night staff needing 4 drills per year. (Req.3) Regulation 26 visits to the home are carried out monthly and reports are sent to the Commission. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 2 3 2 Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(2)(b) Requirement The Manager must keep the service user’s plans under review, up to date and to a consistent standard of recording. The registered provider shall ensure that persons working at the home are appropriately supervised The registered person must ensure that all night staff receives at least 4 fire drills per year Timescale for action 15/04/07 2 OP36 18.2 15/04/07 3 OP30 24(e) 14/04/07 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 OP16 Good Practice Recommendations The registered manager should ensure that all complaints regardless of how trivial are recorded with the date of the complaint the action taken and outcomes of the complaints. Coloma Court DS0000067988.V328031.R01.S.doc Version 5.2 Page 23 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.V328031.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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