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Inspection on 24/01/06 for Thomas Colledge House Care Home

Also see our care home review for Thomas Colledge House Care Home for more information

This inspection was carried out on 24th January 2006.

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

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

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

There is a very stable staff group at the home, that knows the residents well and are very aware of their needs and wishes. One staff member said, "I enjoy coming to work, there is rarely any friction or problems, and any problems are sorted quickly". The environment continues to be of good standard, clean, well decorated and maintained. Residents spoken with were unable to give a clear indication of their level of satisfaction, however they were well-dressed, clean and seemed settled. Staff were observed treating residents with kindness and sensitivity. Although meals were not specifically inspected, there was a good choice at every meal time and one resident spoke highly of the food provided. Residents care plans continued to be clear, up to date and regularly reviewed. Both the staff team and the management team worked well together in a generally open and positive environment. There were good systems in place to protect residents including protection of their money and health and safety. The staff and managers work hard to try to ensure that residents` independence is promoted and they are offered a choice in many aspects of their lives. One staff member said that, "we like residents to try to do a bit for themselves if they can, then we assist with anything that they can`t do as we don`t want to take their independence off them".

What has improved since the last inspection?

As the home was in the process of planning an extension to the care home for 8 residents specifically with dementia, there was no specific improvements planned to the existing service. Some but not all of the previous requirements previously made in October 2005 had been met.

CARE HOMES FOR OLDER PEOPLE Thomas Colledge House Care Home Oxcroft Lane Bolsover Chesterfield Derbyshire DE45 1TB Lead Inspector Jill Wells Unannounced Inspection 24th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thomas Colledge House Care Home Address Oxcroft Lane Bolsover Chesterfield Derbyshire DE45 1TB 01629 580000 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) Derbyshire County Council Mrs Marlene Rhodes Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 Brief Description of the Service: Thomas Colledge House care home is a purpose-built residential home providing personal care for service users over 65 years. The home offers a good standard of accommodation. The care home is situated near to the town centre of Bolsover. There are two wings to the care home. There are no stairs, making the building fully accessible. All bedrooms are equipped with en-suite facilities, including showers. The 16 single rooms all have patio doors opening onto the attractive garden areas. Three of the rooms are used for respite care. There are two lounge/dining room areas, and two bathrooms with assisted bathing facilities. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a 3.5 hour period. During this time three residents were spoken with and three staff members were interviewed. Time was also spent with the registered manager. There were no visitors to the home at the time of the inspection to speak with. Records were inspected including residents’ files. What the service does well: What has improved since the last inspection? As the home was in the process of planning an extension to the care home for 8 residents specifically with dementia, there was no specific improvements planned to the existing service. Some but not all of the previous requirements previously made in October 2005 had been met. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 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. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This set of standards was not inspected on this occasion. It was found at the previous inspection in October 2005 that there was adequate information available for prospective service users. EVIDENCE: Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Service user plans were generally of a good standard, and residents were treated with respect, however there continued to be significant shortfalls in the recording of medication administration. EVIDENCE: Three files were seen as part of the case tracking methods used, and each of the three residents were spoken with. Each resident had a written assessment in place and a service user plan of care. The information within the plans were found to be up to date and accurate. There was however insufficient information in plans concerning social interests and ways that residents could be stimulated. The key worker wrote a monthly report on each resident as a way of updating the care plans. Daily records were also seen and found to be in order. Residents confirmed that they had access to health care services when necessary, and records were made of visits from health professionals. Nutritional assessments were undertaken. Opportunities were given for exercise, and residents were encouraged to walk around the home. Movement to music sessions had recently started and were enjoyed by several residents. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 10 There continued to be issues around medication. Requirements made at the previous inspection had not been met. This included handwritten medication records that had not been signed or countersigned, and several balances within the controlled drugs register again found to be incorrect. The refrigerator for storing medication continued to store food and was not lockable, therefore the medication was still not secure. Staff were now writing the date that medication was started to ensure that out of date medication was not in use. Staff were observed treating residents with dignity and respecting their privacy. Staff spoken with gave examples of how they would ensure that residents privacy was upheld. This included respecting residents wishes to spend time on their own within their own room, knocking on their door and explaining why you have come in, and if residents are safe to be left in the toilet area then this is respected. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Food provided continued to be of good standard with a choice available. Residents were helped to exercise choice and control over their lives. EVIDENCE: Staff were recording organised activities in a very small diary. This record showed several days when there were no activities recorded. At the previous inspection it was highlighted that there was no records of one-to-one consultation with residents or their families concerning activities and stimulation, especially for residents that have some confusion/memory loss. As stated previously this information was not in care plans. The three residents spoken with were unable to give examples of activities, however staff spoken with described some activities that had been organised. This included bingo organised with volunteers, and movement to music. Staff stated that most residents were reluctant to join in with activities. One staff member said when asked about stimulation for residents, we are always sitting talking to residents. Some residents enjoyed listening to music. There had been a Christmas party organised with an outside entertainer. Staff also spoke about a trip to see the Christmas lights at Clowne and a shopping trip to Meadowhall before Christmas. Visitors were encouraged at any reasonable time and were supported to take their relative out if this was appropriate. There were several students from Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 12 Chesterfield College on placement at the home assisting both staff and residents in non personal care activities. One residents spoken with said that they felt that they could exercise choice, and their preference was to remain in their room other than meal times. Staff gave other examples of residents’ choice. This included choosing their own clothes, joining activities, a choice of bath or shower and times for doing this. Staff spoken with knew the residents very well and were aware of their particular needs and wishes. An example was a staff member saying that one particular resident, always liked a bath before Coronation Street. There was a varied diet and meals were taken in a pleasant dining room setting. Residents were offered three meals a day as well as snacks and hot and cold drinks. One resident spoken with said that the food was, very good. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 13 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): 18 There were no concerns identified around safety and protection of residents. . EVIDENCE: There had been no adult protection issues since the previous inspection. The manager had requested training on adult protection issues for staff, although this had not yet been offered. There were good systems in place for protecting residents’ money (see Standard 35). Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 14 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): This set of standards was not inspected on this occasion. At the previous inspection in October 2005 the environment was found to meet the needs of residents living at the home. EVIDENCE: Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 15 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. There were staff on duty to meet the needs of residents. . Safe recruitment practices were taking place. EVIDENCE: Three staff members were interviewed. All staff spoken with were experienced and skilled, and aware of residents needs and wishes. There continued to be two staff on duty at all times, although in the afternoon there was only one staff on duty with a manager who was expected to undertake care duties. A domestic worker was spoken with. They were able to describe safe health and safety practices as well as good levels of training received. At the previous inspection it was highlighted that the home had met the requirement of 50 of staff having undertaken NVQ level 2 Care, therefore this was not discussed at this inspection. Staff files were checked. There was a thorough recruitment procedure in place, which included an application form, two written references, a criminal record bureau check, health declaration and copies of birth certificates for identity. However the manager was not checking any gaps in employment history within individuals application forms as required. One staff member spoken with explained that when they became a relief carer they undertook the relevant induction training. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. The home is well-managed with good health and safety and quality monitoring systems in place. EVIDENCE: The manager had worked at the home for 15 years and was clearly competent and experienced to run the home. The manager had the required NVQ 4 qualification. There was a management team that included the registered manager and three deputy managers. It was evident that they worked well together, each with designated responsibilities. There was evidence that the managers had undertaken relevant training as required. Staff spoken with said that the management approach of the home was open and supportive. Staff felt able to approach the manager with any issues that had arisen, as well as making suggestions for improvement. There were quality monitoring systems in place based on seeking the views of residents and their families. This included an annual review of each resident Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 17 with the service manager present. There were also a regular residents meetings and minutes showed that residents were offered the opportunity to comment on all aspects of the service. Residents and families were given a survey and the quality assurance manager within Social Services analysed the results and wrote a report in response to the analysis. The home was waiting for this report. The service manager visited the home every 2-3 weeks and completed a monthly report, although there had not been a report since 30/11/05. The homes policies and practices regarding residents’ money were good. There was a safe storage of money and valuables and clear, accurate records of any monies kept on residents’ behalf. There were records in place concerning staff supervision and personal development plans, although formal supervision was not taking place at least six times a year. Staff confirmed that they had received training to ensure safe working practices including moving and handling, fire safety, first aid and food hygiene. Hazardous substances were safely stored. There were records of regular servicing including the gas systems, electrical equipment testing, moving and handling equipment and mixer valves on taps. It was confirmed that all bedding, curtains and furniture were flame retardant. There was an annual health and safety audit undertaken. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 3 Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 19 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 OP9 Regulation 13(2) Requirement Timescale for action 30/01/06 2. OP9 13(2) 3. OP9 13(2) 4. OP12 16 (2) (m) (n) Where medication administration records are handwritten (including for respite care residents) the record must be signed by the person completing the record and should be signed by a second person checking the record against the medication label. (Previous timescale24/10/05 not met) The controlled drugs balance of 30/01/06 medication remaining must be checked after every Administration. (Previous timescale 24/10/05 not met) There must be a lockable fridge 28/02/06 to store medication requiring refrigeration. This fridge should not store food. (Previous timescale 30/12/05 not met) All residents must be consulted 30/03/06 concerning their social interests and their needs concerning stimulation. This may require one-to-one consultation and involvement with the key worker and family in some cases. The results of the consultation should DS0000035728.V280050.R01.S.doc Version 5.1 Page 20 Thomas Colledge House Care Home 5. 6. OP7 OP18 7. OP36 be recorded. Action must be taken to try to meet any needs identified. (Original timescale 30/01/06 not met) 15 Individual care plans must include social interests/hobbies/stimulation. 18(1) (c) Care staff must undertake (i) protection of vulnerable adult training. (Original timescale 28/02/06. training requested but not provided) 18 The registered manager must ensure that care staff receive formal supervision at least 6 times a year. 28/02/06 30/04/06 30/03/06 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 3 Refer to Standard OP11 OP12 OP29 Good Practice Recommendations Written policies and procedures should be available in respect of handling death and dying. All activities and opportunities for stimulation should be recorded. Information received from prospective staff should include a full employment history. Any gaps in employment should be explored and explanations recorded. Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Thomas Colledge House Care Home DS0000035728.V280050.R01.S.doc Version 5.1 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. 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