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Inspection on 04/10/05 for South Collingham Hall Care Home

Also see our care home review for South Collingham Hall Care Home for more information

This inspection was carried out on 4th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a domestic and comfortable environment, which is well maintained, in most parts. The manager and staff are very committed to providing good standards of care for the residents. The food is well thought of and residents feel respected and enabled to socialise in a manner that is comfortable for them. The gardens are well maintained and provide a comfortable place to relax, away from noise and traffic. The home`s care planning process and a majority of other documentation required meets the National Minimum Standards.

What has improved since the last inspection?

Not all of the National Minimum Standards were assessed on this occasion. According to residents and relatives the home continues to provide a good standard of care in a comfortable and pleasant environment. Nearly all of the requirements set at the previous inspection have been addressed.

What the care home could do better:

Parts of the home would benefit from refurbishment, though it is acknowledged that some further development at the home is being considered. The laundry area is particularly in need of cleaning, refurbishment and requires other matters to be addressed to comply with Health and Safety regulations. Immediate requirements have been set in respect of this. The care planning framework is very comprehensive, but it was noted that some care plans do not have risk assessments, or where a review has indicated a deterioration in health, with additional support needs, the new action plans for care staff and risk assessments were not present. Whilst it is acknowledged that the home follows the required recruitment procedures, some references were not present and need to be obtained. Also in respect of CRB checks, where offences have been declared, the home needs to evidence what discussion or action has been taken by the manager.

CARE HOMES FOR OLDER PEOPLE South Collingham Hall Care Home Newark Road Collingham Newark Nottinghamshire NG23 7LE Lead Inspector Andrew Sales Unannounced Inspection 4th October 2005 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 South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service South Collingham Hall Care Home Address Newark Road Collingham Newark Nottinghamshire NG23 7LE 01636 892308 0115 9818790 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) Broadoak Group of Care Homes Ms Gloria Brown Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One named service user aged 48 years or older within the category LD as identified in the letter dated 17/9/04 Manager must undertake adult protection training/awareness within 4 months of the registration Service users shall be within category OP Date of last inspection 18th November 2004 Brief Description of the Service: South Collingham Hall is situated on the outskirts of the village of Collingham near Newark. The home provides 24 hour residential care and is registered for 39 beds. At the time of Inspection the numbers of service users was 24. The home is a converted country house of character with extensive grounds and views of the surrounding countryside. The annexe of the home has been refurbished and provides en-suite facilities. The proprietors are considering the refurbishment of the main house bedrooms to provide en suite facilities. To date refurbishment of the lounge and dining room in the main house has been completed. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by A.J.Sales on 4 October 2005. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The inspector also spent time talking to other residents in the home, two members of staff and a relative of one of the service users. Overall the feedback was very good. Residents were happy to express their views about the home, they were positive in terms of the skills and attitude of the staff and of the overall standards of care, food, social recreation and the environment. What the service does well: What has improved since the last inspection? Not all of the National Minimum Standards were assessed on this occasion. According to residents and relatives the home continues to provide a good standard of care in a comfortable and pleasant environment. Nearly all of the requirements set at the previous inspection have been addressed. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 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. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. The Statement of purpose and service user guide are the Broadoak Company document and includes details of South Collingham Care Home. The statement of purpose and service user guide meets NMS. Service users are assessed prior to entering the home. EVIDENCE: The Statement of Purpose and the Service User Guide was inspected and complies with this standard and the current registration details. The records of three service users, were checked as part of this inspection. One person had an extended social work assessment, which had been obtained prior to their admission. Other files contained assessments conducted by the manager. All of the assessments were comprehensive and contained sufficient information to enable staff to ensure that they could meet the service users assessed needs. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Service users receive a comprehensive assessment. Assessments are not always updated following a review. The home is able to meet the healthcare needs of it’s residents. Medication issues are manager appropriately. Service users are treated appropriately. EVIDENCE: All of the service users whose records were checked as part of this inspection had comprehensive service user plans. The records show that the plans are being reviewed at least once each month and that service users, and where appropriate their representatives, are being involved in the review process. The service user plans also contained risk assessments, which are also reviewed each month. However one plan observed, detailed further assistance required with transferring, following a review. The plan did not detail instructions for care staff of what assistance was required and did not provide details of risk assessments in relation to these additional daily support tasks. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 10 Service user plans contain details of each service users individual health care needs, including a tissue viability and continence risk assessments. There is evidence that people have been appropriately referred to health care professionals. Care plans viewed contained records of visits by district nurses, General Practitioners and other professionals. Healthcare professionals were observed visiting on the day. The inspector was informed that a number of doctors surgeries are used to ensure that the service users can register with a GP of their choice. Staff training records that were viewed, evidenced that medication training was provided for staff responsible for the administration of medication. At the time of the inspection no service users self medicate. The home uses the group policy and procedure for receipt, recording, storage handling administration and disposal of medication. The home’s medication records were not observed as part of this inspection. Staff were observed during the visit interacting positively with individuals, a relative spoken with, reported staff provide a good standard of care and areas of concern would be discussed with the registered manager. Three service users spoke with the Inspector and commented very positively on the conduct and attitude of the staff. Induction and training records viewed, included instruction on entering service users rooms, care practices and confidentiality. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15. Service users are supported to access daily activities and access the local community. Service users maintain contact with family and friends. Food provided at the home is considered to be acceptable by the residents. EVIDENCE: Service users spoken with felt they were happy with the level of activities within the home and outside. The staff reported that they encourage service users to participate in events and outings. Planned trips and events are organised within the home. Some service users felt they could only access certain activities depending on which staff were on duty. It is felt that an activities organiser within the staff team would benefit the residents. Relatives and service users spoken with, commented that were made welcome at any time when visiting the home. Service users were observed briefly, eating lunch during the visit. The food provided looked nourishing and appetising. Service users spoken with commented positively on the standards and quality of food. Staff spoken with were well aware of service users individual preferences. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The home operates suitable complaints and adult protection procedures. EVIDENCE: The home has a comprehensive complaints procedure, that meets the NMS, which is appropriately displayed, throughout the home. Service users and relatives spoken with, stated they would raise concerns with the registered manager and the proprietors. Complaints records were not observed on this occasion. The home has an appropriate Whistle Blowing Policy and a policy detailing Adult Protection Procedures. The homes policies and procedures for responding to suspicion or evidence of abuse, or neglect, are all satisfactory. The home has comprehensive policies regarding service users money and financial affairs. The two staff members spoken with, had attended training in adult protection and demonstrated a positive awareness of exposing abuse and bad practice. Training certificates were observed on staff files. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26. The home was appropriately clean and tidy at the time of this inspection. The Laundry area requires cleaning, refurbishing and washing facilities for staff. EVIDENCE: The home appeared clean and generally well maintained. Residents spoken with, felt comfortable in the environment. The laundry was found to have no impervious floor surface, an unused manual sluice was blocked with indescribable waste, there was no soap, disinfectant or hand towels present for staff. As some of these issues were raised some two years ago, an immediate requirement was issued. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,30. Staff are recruited and employed in suitable numbers. Staff are trained in mandatory subjects required by this standard and for care specific support. EVIDENCE: On the day of inspection there were two care staff, one senior care staff, the registered manager, one cook and one domestic staff on duty. From the staff rota provided, the staffing levels meet requirements, with the current resident occupancy levels being 24. There are suitable recruitment policies and procedures that have been observed at previous inspections. Three staff files were sampled at random. These contained evidence of applications, interviews, pre employment checks, criminal declarations, confidentiality agreements, supervision and training plans. One file contained a CRB with disclosures. Whilst these were dated some time ago, there was no evidence of any discussion the manager may have had over this issue. There were also no references on this file. An immediate requirement was set in respect of this. Staff spoken with informed the inspector of various training courses they had attended, which included, adult protection and the safe handling of medicines. Of the three staff files examined, they all contained evidence of training in a number of health and safety subjects, dementia awareness, NVQ level 3, staff supervision and appraisal plans. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36,38. Residents are consulted over issues in the care home. Staff are appropriately supervised. Health and Safety is generally well managed. EVIDENCE: Evidence of residents surveys was found on individual care plans. Residents also felt they were consulted about day to day issues. It is recommended that surveys contain evidence of who, how and when the survey was completed. The home operates a standard company induction procedure. The manager reported that she supervises and completes appraisal for all the senior and care staff. Records of appraisal were viewed. All staff files contained records of supervision and appraisal. Staff spoken with also supported this process. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 16 The home has the Broadoak group Health and Safety policies and procedures which are comprehensive. Staff training files viewed evidenced staff have undertaken all mandatory training in health and safety. Staff spoken with were aware of health and safety procedures and commented positively on the training provided. Risk assessments are in place for the building and individual service users. Records for Health and Safety monitoring were not inspected on this occasion . South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 1 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 3 South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 18 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 7 Regulation 15 (1) Timescale for action “The Registered person shall, 30/10/05 after consultation, prepare a written plan (the service users plan) as to how the service users needs in respect of his health and welfare are to be met.” Ensure details of action plans for staff are recorded following a service users review of care. “The registered person shall 30/10/05 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated and arrangements are made to provide a safe system for moving and handling service users.” Ensure risk assessments are completed following a change identified in service users mobility needs during the review process. 3 26 13.(3) “The registered person shall 30/10/05 make suitable arrangements to prevent infection, toxic conditions and the spread of DS0000024661.V256659.R01.S.doc Version 5.0 Page 19 Requirement 2 7 13 (4.C,5) South Collingham Hall Care Home infection at the care home.” Ensure the laudry is kept clean and tidy, with adequate washing facilties for staff. “The Registered person shall 30/12/05 arrange for the regular laundering of linen and clothing; provide adequate facilities for service users to wash, dry and iron their own clothes if they so wish and, for that purpose, to make arrangements for their clothes to be sorted and kept separately; after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home.” Refurbish the laundry area to ensure the laundry floor finishes are impermeable and these and wall finishes are readily cleanable. “The registered person shall not 30/10/05 employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 6 of Schedule 2.” Ensure two references are sought for each applicant. “The registered person shall not 30/11/05 employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 7 and 8 of schedule 2. Ensure that any disclosures are discussed and outcomes South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 20 4 26 16 (2, e,f,j.) 13.(3) 5 29 Reg 19. sch 2(5) 6 29 19.Sch 2 (7,8) recorded on the file individual applicant of the 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 33 Good Practice Recommendations It is recommended that service users surveys evidence source of information, date and method used in completing the survey. South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI South Collingham Hall Care Home DS0000024661.V256659.R01.S.doc Version 5.0 Page 22 - 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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