Inspection on 11/10/06 for Colonia Court

This inspection was carried out on 11th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Colonia Court 15/12/09

Colonia Court 17/09/08

Colonia Court 25/09/07

Colonia Court 14/03/06

Colonia Court 10/03/06

Colonia Court 10/01/06

Colonia Court 19/12/05

Colonia Court 03/11/05

Colonia Court 15/03/05

Colonia Court 01/02/05

Colonia Court 13/01/05

Colonia Court 09/12/04

Colonia Court 09/11/04

Colonia Court 13/07/04

Colonia Court 07/07/04

Colonia Court 22/06/04

Colonia Court 15/06/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE Colonia Court St Andrews Avenue Colchester Essex CO4 3AN Lead Inspector Francesca Halliday Key Unannounced Inspection 09:00 11 – 19 October 2006 th 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 Colonia Court DS0000015331.V314933.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. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colonia Court Address St Andrews Avenue Colchester Essex CO4 3AN 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) 01206 791952 01206 794230 www.bupa.com BUPA Care Homes (CFHCare) Limited Harvey Newman Care Home 110 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number disorder, excluding learning disability or of places dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4), Old age, not falling within any other category (30), Physical disability (3), Physical disability over 65 years of age (30) Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. Amber Lodge Persons of either sex, under the age of 65 years, who require nursing care by reason of Huntington’s Disease (not to exceed 20 persons) Persons of either sex, under the age of 65 years, who require care by reason of Huntington’s Disease (not to exceed 20 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of Huntington’s Disease (not to exceed 4 persons) Blomfield House Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 30 persons) Mumford House Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 30 persons) Paxman House Persons of either sex, aged 50 years and over, who require nursing care by reason of a physical disability (not to exceed 3 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 30 persons) The total number of service users accommodated not to exceed 110 persons 14th March 2006 Date of last inspection Brief Description of the Service: Colonia Court is registered to provide nursing and care for up to 110 residents. The site is separated into four houses. Residents are accommodated in single rooms, all with en-suite toilet and basin. Each house has a good range of communal rooms and the accommodation is all on one level. The houses are staffed on an individual basis and the central services include administration, laundry and kitchen. The home has car parking facilities and gardens attached to each house. Colonia Court is set in a residential area and is approximately one mile from Colchester town centre and two miles from the railway station. Buses run along St Andrews Avenue outside the home. Paxman House is registered to provide nursing care for up to 30 residents over the age of 65 and up to 3 residents over the age of 50, who require nursing care because of a physical illness or disability. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 5 Amber Lodge is a 20 bedded specialist unit for residents over the age of 18 years with Huntington’s Disease. Mumford House is registered to provide care for up to 30 residents over the age of 65 who have dementia. Blomfield House is registered to provide care for up to 30 residents over the age of 65. The range of fees at Colonia Court in October 2006 were: personal care £590 - £630, nursing care £600 - £630, care for Huntington’s Disease £2000 £2700. The fees were dependent on assessments. The higher range of fees on Amber Lodge for Huntington’s Disease was for 1:1 or 1:2 care. Items such as toiletries, newspapers, hairdressing and private chiropody were charged for separately. The home had a range of information for potential residents and their representatives. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection site visits to Colonia Court took place over three days from 11th to 19th October 2006. The inspection process included discussions with 18 residents (although advanced dementia and Huntington’s disease made communication difficult with some residents), 6 relatives, and 17 members of staff including the general manager, deputy manager and head of care. A visiting GP, community nurse and social worker were also spoken with. 33 residents’ survey forms were returned prior to the inspection, a few of which had been completed by relatives on residents’ behalf. The premises and a sample of records were inspected. 22 standards were inspected: 2 exceeded the standard, 10 met the standards and 10 standards had minor shortfalls. What the service does well: What has improved since the last inspection? A deputy manager and head of clinical care had been appointed in addition to the general manager. There was evidence of improved management support for staff and closer monitoring of standards within the home. The overall standard of care documentation had improved and was more resident centred than in the past. The standard and range of activities was improving and links to the community were being developed, but staff must ensure that the needs of residents with sensory deficits are considered when devising activities. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 7 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. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 8 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 Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. The home has a good pre-admission assessment system in place, which ensures that the home can meet the needs of new residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and relatives generally considered that the pre-admission assessment process had been managed well, and they had been given the appropriate information prior to making a decision on admission to the home. One relative said “The administrator and carers were very helpful at a stressful time”. A resident described the process as “Very open and helpful”. The assessments seen were generally detailed, but on some occasions would have benefited from combining the two assessment tools in use at the home, to ensure that more information about the potential resident was recorded. Colonia Court DS0000015331.V314933.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. Residents consider that their health and care needs are met. Care documentation is resident focused and the standard of documentation is improving. Medicine administration is generally managed well and action is being taken to address areas where improvements need to be made. Residents consider that staff respect their privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents surveyed and spoken with said they were very happy with the standards of care. Two health professionals and a social worker spoken with said that the standards at the home, and communication with them, were very good. The records on each house were sampled and an overall improvement in the standard of care documentation was noted. The care plans were more resident focused than in the past and there was evidence that residents, and relatives where appropriate, were being more involved in the development of the care plans and evaluation of care and care needs. Some of the care plans Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 11 would benefit from being more specific about residents abilities and how staff could encourage them to maintain life skills. The daily progress records were generally of a good standard and demonstrated monitoring of care needs and links to the care plans. There was evidence of monitoring of residents’ psychological health where appropriate. There was a range of risk assessments in place, which had been regularly reviewed. However, some of the risk assessments were standardised and were not actually assessing the risk to the individual resident. On Blomfield the senior carers were writing the progress records for the whole day on the evening shift, regardless of the fact that they had not been present during the morning. A record about residents on the morning shift was being written in a separate book. Night and day progress records were being kept separately so that there was a lack of continuity in the daily records. Two books on Blomfield were being used to record details of residents’ care and needs. The head of care was advised that information about residents must be kept in individual records and that the books did not comply with the Data Protection Act 1998. Some care needs identified during discussions with residents and staff had not been included in the care plans. One residents on Blomfield had bruises on both arms, which they said had been caused during hoisting; this had not been documented in the care or accident records. Staff said that they generally had excellent support from local GPs. There was evidence that there was input from the community psychiatric nurse who assisted with assessments and review of medicines when needed. A consultant psychiatrist visited residents on Amber Lodge on a fortnightly basis. Residents said that they had dental and optical checkups and chiropody when needed and said that they had good support from their GP. However, a number of residents on Blomfield House had long toenails that were in need of attention. Staff said that they would request a further visit from the chiropodist. Residents’ weight was monitored regularly and supplements provided when necessary. Residents with more specialised nutritional needs had access to a dietician and to speech and language therapists for swallowing assessments. There was evidence of referrals for physiotherapy and occupational therapy assessments. The home had a good range of pressure relief equipment and systems in place to obtain additional equipment if needed. There was evidence that staff on Paxman House had provided excellent care to a resident with a hospitalacquired pressure sore and healed it in a very short period of time. A number of residents on Paxman House said that they sometimes had a long wait for assistance to go to the toilet because one electric hoist had been out of action, or only working very intermittently, for a number of weeks. A relative on Blomfield House was concerned about the amount of equipment in a resident’s en-suite. This was clinical equipment, which was used by the community nurse. It was in open packets and was being stored directly on the floor next to the toilet. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 12 Staff on Amber Lodge had referred some residents to the advocacy services so that they could be assisted to make decisions about their choices for end of life care. The charge nurse said that they were encouraging residents to develop “living wills” and discuss the care that they might wish to have in the future. For example whether they would wish to be fed via a PEG or be transferred to hospital if their condition deteriorated, and they were unable to voice an opinion at that stage. A ceiling hoist was due to be installed in one resident’s room on Amber Lodge. The management and administration of medicines was of a good standard on Paxman House and Amber Lodge. The standard was generally good on Mumford House, however, the homely remedies stock balance for one medicine was incorrect and the temperature of the clinical room was not being monitored daily. Staff said that the supplying pharmacist was due to carry out a medication review and provide some staff training across the site. The standards of medicines management on Blomfield House needed some improvement. It was not always possible to establish whether prescribed medicines had been given, as staff had on occasions crossed out a signature on the medicine administration records (MAR) and written “error” without giving an explanation on the back of the MAR. The stock balances of some “as required” medicines were not correct and the administration of variable doses of medicines needed to be clearer. Staff were dissolving one medicine, in a modified release form, in water. Staff said that this had been agreed with the GP. However, this practice had not checked with the pharmacist as to whether the fast absorption of a medicine, which should be released over a number of hours, would be detrimental to the resident. A recent medication audit had been carried out across the site, and action was being taken to address the issues identified. Residents across the site said that staff respected their privacy and dignity and treated their room as their private space. However, one resident on Paxman House said that while the nurses always knocked before entering the care assistants did not always do this. Colonia Court DS0000015331.V314933.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. The range and standard of activities is improving and links with the local community are being developed. Residents are offered genuine choices and independence is encouraged. Residents’ nutritional needs are met and they are generally very satisfied with the food offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents reported that more activities were now being offered. The manager said that links were being developed to the National Association for Providers of Activities for Older People (NAPA), and they hoped to use the association for staff training. The majority of staff had received some initial training in providing stimulation and activities. The training emphasised the importance of all staff taking responsibility for interacting regularly with residents, providing interest and stimulation and ensuring that there were a range of activities on offer to suit different needs and interests. There was evidence of improved liaison between the activity coordinators across the site with residents being encouraged to join activities on other houses. This increased the variety of activities available to residents across the site. There was evidence that staff other than activity coordinators were taking part in Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 14 activities and providing a more stimulating environment for the residents. However, this still needed to be fully developed across the whole site. There was evidence that staff needed to consider the specific needs of some residents with poor sight or hearing, who could be disadvantaged by some of the activities offered. Two services were held on Paxman House each month and residents from other houses were invited to attend. The clergy also visited residents on other houses who were unable to attend the services. There was evidence of visits to the local shops, pubs, cinemas, garden centres and local places of interest. There had been an improvement in the number of short trips and longer outings out of the home. A PAT dog visited the home on a weekly basis. Residents had enjoyed a fish and chips lunch on Blomfield House and residents from other houses had attended. A “pink day” in aid of cancer research had been recently held in the home, when all the staff wore pink. Staff were taking steps to improve links to the local community. Local people in the area had been invited to the summer fete. Links with the local hospice had been improved and arrangements had been made for an art therapist to visit a resident on Amber Lodge. A resident on Amber lodge had also been enrolled on a computer course. One of the small sitting rooms on Paxman House had been made into an arts and crafts room. Relatives said that they were always made to feel very welcome. There was evidence that residents were being offered genuine choices and encouraged to maintain independence. Residents and relatives were able to give a number of examples of how staff made efforts to meet residents’ wishes and choices and encouraged independence. The kitchen was clean and appeared well organised. The chef described the new menu assessment tool, which was used to ensure that residents were offered a balanced and nutritious diet. The majority of residents surveyed said that they were “usually” satisfied with the meals and some said that they were “always” satisfied. A few residents were only satisfied “sometimes”. One resident spoken with considered that the standard of food was variable and that overall it had not been as good in the past 3-4 months. Another considered that there should be more fresh vegetables offered and said that the main meals “were a bit monotonous”. The chef said that they tried to offer one fresh and one frozen vegetable each day, but that the ability to offer fresh vegetables was dependent on deliveries. Choices were available at each meal and residents were aware that they could have alternatives if they did not like what was on the menu. There was evidence that staff were supporting residents who found it difficult to make choices on their own. Staff on Amber Lodge demonstrated a good understanding of the changing dietary needs of residents with Huntingtons Disease. A number of residents on Blomfield House said that the food was often not served to them at the right temperature. One resident said “They Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 15 serve hot food on cold plates. Some food isn’t nice, I can’t eat it when it gets cold”. This has been raised as an issue on Blomfield House in the last two inspection reports. Colonia Court DS0000015331.V314933.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. Residents and relatives are confident that complaints or concerns are addressed promptly and that residents are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure. Residents and relatives knew who to contact if they had any concerns or complaints, and said that any concerns or problems were dealt with very promptly. There was evidence of appropriate investigation and action taken in response to complaints or concerns raised. The home had a policy on the protection of vulnerable adults, which included a whistle blowing policy. The induction provided an introduction to the issues surrounding abuse and actions to take if abuse was suspected. The majority of staff had received training in the protection of vulnerable adults (POVA), and further training was being arranged. Residents said that they were very happy with the staff and the care provided. Relatives spoken with and surveyed were confident that care was being provided in a manner that was in the residents’ best interests, and protected them from harm. Staff spoken with had an understanding of the types of abuse that could occur, and the action to take if any poor practices or abuse was suspected. Colonia Court DS0000015331.V314933.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. The home is clean, well decorated and well maintained. New furniture and furnishing are due to be ordered shortly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a rolling programme for redecoration and refurbishment. A number of residents’ rooms and communal areas had been redecorated since the last inspection. The manager was aware that some of the armchairs needed to be replaced. He said that new dining tables and chairs and bedside tables would also be ordered in the near future and a number of the soft furnishings and bed linen would be replaced. Residents’ rooms were very well personalised. There was evidence that they were involved in choosing colour schemes for both their rooms and for some communal areas. The office on Blomfield House was due to be moved to an area adjacent to the main lounge/dining room. This would improve the ability of staff to monitor and Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 18 assist residents. The sensory room on Amber Lodge had been much improved. The dining area on Paxman House had been made more homely by new tablecloths and flowers on the tables. The garden attached to Mumford House was very attractive and an aviary was being built there to add more interest for residents. The home was clean and there were no unpleasant odours in any of the houses visited. The laundry looked clean and well organised. Staff said that they labelled any clothes that had not been labelled by the resident or their family. Residents said that they were very happy with the laundry service. Residents generally described it as “good” or “excellent”. Laundry staff confirmed that staff sent soiled linen to the laundry in appropriate bags. One member of staff described how standards of infection control had been improved by the introduction of antiseptic gel for visitors to the home and wet wipes for residents prior to meals. Colonia Court DS0000015331.V314933.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. Staffing levels are satisfactory for the number and dependency of residents, but the home needs to ensure that all foreign staff have a good command of English. All staff have a formal induction. Recruitment procedures are generally sound. The management team are aware of training needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with were generally satisfied with the staffing levels, although a few residents considered that they sometimes had a long wait for assistance to go to the toilet (see standard 8 re problems with hoist on Paxman House). Residents and some relatives said that communication with a minority of foreign staff could be difficult. One resident said “I don’t feel very safe because I can’t understand what they’re saying and they don’t always understand my needs”. Staff received a one day initial induction, which was classroom based and then had the full induction on each of the houses. The induction was linked to Skills for Care and the duration was dependent on the needs of the individual member of staff. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 20 The personnel records were sampled and the recruitment procedures were seen to be generally sound. Criminal Records Bureau checks and references had been obtained. However, full identification was not available for all staff, and interview records were not available for staff recruited abroad or transferred from another BUPA home. There were systems in place to check that nurses had maintained their registration with the Nursing and Midwifery Council, but regular checks were not being carried out to see if any nurses had been removed or suspended from the register. In-house training in Huntington’s disease had been developed for staff on Amber Lodge. However, only a third of staff had completed the training. The majority of staff on Amber Lodge had received de-escalation training. A number of staff on other houses needed training in the management of challenging behaviour and some staff needed dementia care training. A few staff had received training on the care of people with Parkinson’s disease, but this training needed to be given to all staff who provided care for residents with Parkinson’s disease. The home did not meet the standard for 50 of care assistants completing National Vocational Qualification at level 2. A number of staff needed nutrition training, care of the resident with diabetes and the prevention of pressure sores. Some nurses needed training in wound care, nutrition and the management of PEG feeding. The head of clinical care, who had recently been appointed, was due to take over responsibility for training and the senior management team were aware of many of these training needs. Colonia Court DS0000015331.V314933.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 36, 38 Quality in this outcome area is good. The home is well managed and has a strong senior management team. There are systems in place to monitor and constantly improve standards of care and services. The systems for managing residents’ monies are sound. Staff are well supervised. The health and safety of residents is promoted and regular training in safe working practices is given. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A deputy manager and a head of clinical care had been appointed since the last inspection, in addition to the general manager. There was evidence of increased monitoring of standards of care and services and of prompt action taken to address any identified issues. Staff said that they felt well supported by the management team. A manager was on call throughout the 24 hours to Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 22 provide advice and support to staff. A number of residents and relatives said that they had excellent support from the senior staff on the individual houses. A relative said, “We’re happy with the way the home is being run”. The company had a quality assurance programme with systems in place to regularly monitor the quality of services and care. This included audits of health and safety, administration, human resources and independent satisfaction surveys. There were also regular internal audits for example of care documentation, medicines management, infection control and the environment. There was evidence of prompt action taken to address issues identified and a commitment to constantly improving the quality of services and care. A large number of staff had completed a “personal best” course. The course encouraged staff to reflect on the care and services they were providing, and to identify areas where they could improve and provide their personal best. There was evidence that the course helped staff to provide more resident centred care. The home had good systems in place for management of residents’ monies. There was clear accounting for each resident’s monies, and receipts were available for all expenditure. The money was held in a central account but interest was apportioned individually. The BUPA finance department carried out both announced and unannounced visits to audit the financial management in the home. The induction programme provided an introductory session on safe working practices. The home then had a rolling programme of more in-depth training. The majority of staff had received fire training. Training booklets for health and safety, food hygiene and infection control had been ordered for staff that needed training or an update. A number of staff needed moving and handling and Control of Substances Hazardous to Health (COSHH) training or updates in their training. There were systems of formal supervision in place throughout the home. Accidents were generally well documented and included the actions to take to reduce the risk of further accidents taking place. (However, see standard 8 re the recording of all bruising on accident records) The manager said that an informal audit of residents’ accidents was carried out. A discussion was held about the benefit of formalising the audit and analysing the accidents. No obvious hazards were noted during the inspections, apart from a broken bath surround with sharp edges and residents seen in the equipment store on Mumford House. The bath surround was replaced and a lock put on the equipment room door promptly following the inspection. Some paving stones were uneven and the manager said that they were waiting for quotes to get them re-laid. There was a notice advising people of the uneven paving. There was evidence of regular servicing and maintenance of equipment. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 3 X 2 Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement The registered person must ensure that: 1. Care plans cover all assessed needs. 2. Care records are kept in residents’ individual folders and there is continuity between the day and night records. 3. Staff only write daily records about the shifts when they have been on duty. 4. Accidents or bruising is appropriately documented. These requirements apply to Blomfield House only. Informed at the time of inspection. The registered person must ensure that: 1. There are sufficient hoists to meet the needs of residents on Paxman House. 2. Clinical equipment on Blomfield House is stored appropriately. 3. Risk assessments are personalised to the individual resident. DS0000015331.V314933.R01.S.doc Timescale for action 19/10/06 2. OP8 14 01/12/06 Colonia Court Version 5.2 Page 25 3. OP9 13(2) The registered person must ensure that: 1. An accurate record is made of the administration of homely remedies and the clinical room temperature is monitored daily on Mumford House. 2. An accurate record is made of the administration of “as required” medicines and medicines are not crushed or dissolved in drinks without first checking this practice with a pharmacist. This requirement refers to Blomfield House. Informed at the time of inspection. The registered person must ensure that the needs of residents with sensory impairments are considered when devising and arranging social activities. The registered person must review the systems of meals distribution on Blomfield House, and ensure that food is given to residents at the appropriate temperature. Informed at the time of inspection. Requirement in previous reports - timescales of 01/02/06 and 01/07/06 not met. Informed at the time of inspection. The registered person must ensure that staff are only employed if they have a good command of the English language. The registered person must ensure that full identification is available for all staff and that a regular check is made with the NMC of nurses who have been DS0000015331.V314933.R01.S.doc 19/10/06 4. OP12 16(2)(m) (n) 01/12/06 5. OP15 16(2)(i) 19/10/06 6. OP27 12(1)(a) 19/10/06 7. OP29 19(1) 01/12/06 Colonia Court Version 5.2 Page 26 removed or suspended from the register. 8. OP30 18(1)(c) The registered person must ensure that the training needs identified in standard 30 are addressed. The registered person must ensure that all staff are up to date in their moving and handling and COSHH training. 01/04/07 9. OP38 13(5) 01/01/07 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. 2. Refer to Standard OP28 OP29 Good Practice Recommendations The registered person should ensure that there are a minimum of 50 care assistants trained to NVQ level 2. The registered person should ensure that interview records are obtained for staff recruited from abroad and that an interview is recorded when staff are transferred from another BUPA home. Colonia Court DS0000015331.V314933.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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