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Inspection on 24/10/05 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 October 2005.

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

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

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

It was evident from discussions with staff, as well as observations, that the staff knew the residents well and were aware of their needs. The environment was of a good standard. It was clean, well decorated and maintained. There was a high level of satisfaction expressed by service users during the inspection visit. Comments included "staff couldn`t be any better" and "I couldn`t be happier anywhere else". Meals were of a good standard, and again residents were very satisfied with meals provided. Residents, views was that staff would accommodate any requests concerning alternative food. Residents care plans were clear, detailed and up-to-date.

What has improved since the last inspection?

Since the last inspection the service user guide and statement of purpose had been reviewed and now meets the requirements. Each service user has a copy of the service user guide, which is clear and detailed.

What the care home could do better:

It was of concern that the medication administration records and storage of medication were not of a good standard. There were significant errors that could potentially put service users at risk. Feedback was given to the service manager at the time of the inspection and immediate action was required. Although there was a worker responsible for activities, there were few activities recorded, and none were advertised within the home. Although group consultation took place concerning alternative activities, there was no evidence of one-to-one consultation taking place. It was however accepted that there were times when residents were difficult to motivate.

CARE HOMES FOR OLDER PEOPLE Thomas Colledge House Care Home Oxcroft Lane Bolsover Chesterfield Derbyshire DE45 1TB Lead Inspector Jill Wells Unannounced Inspection 24th October 2005 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.V261158.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. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 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.V261158.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 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.V261158.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a four-hour period. Four residents and a visitor were spoken to during the inspection visit. The deputy manager on duty, a care assistant and the service manager were also involved with the inspection. Three residents’ files were inspected as part of the case tracking method used. It was stated during the inspection visit that there was a proposal to build an extension to the care home. This was likely to be 8 beds specifically for residents with dementia, in order to meet the increasing needs for dementia places in the local area. At the time of the visit Derbyshire County Council Social Services had not placed an application concerning the extension with the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Since the last inspection the service user guide and statement of purpose had been reviewed and now meets the requirements. Each service user has a copy of the service user guide, which is clear and detailed. Thomas Colledge House Care Home DS0000035728.V261158.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. Thomas Colledge House Care Home DS0000035728.V261158.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 Thomas Colledge House Care Home DS0000035728.V261158.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, 5 There was adequate information available for prospective service users, and needs were assessed before service users were offered a place at the home. EVIDENCE: There was a statement of purpose and service user guide available at the home. These had recently been revised and were now in line with the requirements. It was stated that each resident had their own copy of a service user guide. Both documents explained what to do if a person was not satisfied with the service, and includes the name and address of Commission for Social Care Inspection. The service user guide stated that prospective service users are offered a place on a trial basis, which is usually for six weeks. At the end of the trial period, service users will be asked to confirm their wishes regarding remaining at the home. Emergency admissions were accepted when necessary, although this was avoided wherever possible. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 9 Three residents’ files were inspected as part of the case tracking methods used at inspection. All had a detailed assessment in place, undertaken at the time of moving into the home. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 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, 11. Service user plans were detailed and of a good standard. However there were significant shortfalls in the recording of medication administration, which could potentially put service users at risk. EVIDENCE: All three files that were seen had a detailed service user plan in place. It was evident that these have been drawn up with each service user, and service users were asked to sign them where appropriate. The plans were reviewed on a regular basis and updated to reflect changing needs. There was evidence in residents’ files, as well as through discussion with residents that they receive access to health care services when necessary. Nutritional assessments were undertaken. A resident spoken to said that they were registered with the GP of their choice. Residents have access to hearing and sight tests, dental and chiropody services. There were two residents that partly self-administered their medication. Staff were signing that they had passed this medication to the resident, however the resident was not signing that they had received this medication. There were some significant errors within the medication administration records. This included gaps in records where medication had been Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 11 administered and not signed for. Handwritten medication records had not been signed by the person completing the record or checked and countersigned by a second person. Controlled drugs were inspected. A controlled drug administered the morning of the inspection had not been recorded within the register. Several balances within the controlled drugs register were checked, and one was found to be incorrect. This was due to a recording error two days previously that had not been highlighted by subsequent staff. The refrigerator for storing medication was also storing food and was not lockable, therefore the medication was not secure. There was out of date medication being used, namely eye drops. At a previous inspection it had been highlighted that there was no written policy and procedure concerning handling death and dying. This was still the case. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15. There was limited social activities and stimulation available, and it was unclear whether residents’ social interests and needs were satisfied. Food provided was of a good standard with choice available. EVIDENCE: There was a care worker responsible for organising activities. This worker had an activities record book, which was inspected. For a significant period of time there had only been bingo and a pamper day recorded within this book. It was explained that the worker is on duty two days a week, and other activities taking place for example dominoes and cards were often not recorded. Residents meeting were evidence that residents were offered the opportunity to suggest alternative activities. The manager stated that it was becoming increasingly difficult to motivate many residents. It was suggested that individual residents needs and wishes concerning activities and stimulation could be discussed and recorded on a one-to-one basis. There was a degree of routine within the home including mealtimes and days for activities. Residents spoken to seem to enjoy this routine. It was stated that religious observance no longer took place at the home due to very few residents wishing to participate when this was offered. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 13 Residents spoke about a trip to Cleethorpes last August and a shopping trip for Christmas that was hopefully planned. There had also been an event at the home to raise money for breast cancer. There was transport available when a trip was organised. Residents spoke highly of the food provided. Comments included the food is lovely, and there is a good choice of food, staff will always try to please you. Residents were told at the beginning of the day what was for lunch and tea. They were asked if this was acceptable and if not an alternative was offered. Alternatives always available were jacket potato, eggs, soup, and fish. Teatime was often sandwiches, although there was a cooked tea twice a week. There was a menu displayed at the home, however on the day of the inspection this did not display the correct menu. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Residents were encouraged and supported to complain, and complaints were taken seriously. EVIDENCE: There was a written complaints procedure displayed at the home as well as in the service user guide. Informal as well as formal complaints were recorded which was good practice. The name address and telephone number of the Commission for Social Care Inspection was available if anyone wishes to take a complaint further. There had been no allegations of abuse. Although there were procedures for responding to suspicion or evidence of abuse, staff had not undertaken protection of vulnerable adults training. It was stated that this was planned. The homes policies and practices regarding service users money were not inspected on this occasion. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, 26. The environment met the needs of the residents living at the home EVIDENCE: The location and layout of the home was suitable for its stated purposes. It was accessible, safe and well maintained. Decoration and furnishings were comfortable and homely. Grounds were kept tidy. The management team had recently undertaken training in minimising sources of legionella. There was now a clear written policy and procedure and all relevant checks concerning water storage and distribution temperatures were taking place. At the time of inspection the home was at a comfortable temperature. Residents spoken to said that the home was always comfortably warm. The premises were clean and, and free from any offensive odours. A visitor spoken to at the time of the inspection said that this was always the case. Laundry facilities were sited so that it did not intrude on residents, and washing facilities were available within the laundry area. The laundry floor Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 16 finishes were impermeable and the wall finishes were readily cleanable. The washing machine met the specified programming ability to meet the required standards. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 There were adequate staff to meet the needs of residents. was available for all staff. EVIDENCE: Relevant training The statement of purpose stated that staff hours at the home were 37 overall management hours, 87 hours managers (undertaking care), 167 hours care (day) and 119 hours care (night), 42 hours catering and 48 hours domestic duties. The manager stated that these hours were being followed. It was stated that there were two care vacancies at the time of the inspection, a 16-hour post and an 11-hour post. The 16-hour post was due to be filled. There were always two staff on duty, however there were times when the second person undertaking care hours was also the manager on duty. There were 7 care staff that had undertaken NVQ 2 Care or above. This was above the 50 requirement. There was also two staff that had undertaken NVQ 1 Cleaning, which should be commended. Training records showed that moving and handling, first aid, health and safety, basic food hygiene and fire safety were all available as mandatory training. Several staff had also undertaken dementia awareness, sensory impairment and HIV/AIDS awareness training. As previously discussed care staff had not undertaken protection of vulnerable adult training. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 18 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, 32,37 The manager was experienced and had the required qualification. The management approach of the home was open and positive. EVIDENCE: The registered manager had managed the home for a number of years. She had obtained the required NVQ 4 qualification. There were clear lines of accountability within the home and with the external management. The service manager responsible for the service visited the home after being made aware of the inspection. Therefore feedback was given directly to the service manager as well as the manager on duty. Staff and several residents said that the managers approach was open and positive. There were strategies for enabling staff, and service users to affect the way that the service was delivered. This was in the form of staff meetings, residents meetings, questionnaires and reviews. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 19 Management practice encouraged innovation and development. This included giving care staff undertaking NVQ Care the opportunity to review risk assessment forms. The management team also had individual responsibilities for various aspects of the running of the home including activities, medication, care plans and housekeeping. The homes record-keeping was of a good standard. Daily records concerning service users were available. Records were held securely. Staff records were not inspected on this occasion. Relevant information was displayed including the registration certificate and the employers liability insurance certificate. The service manager responsible for the home had completed some reports as required concerning the conduct of the care home, and visited on a fortnightly basis. The reports that were seen included an inspection of the premises and discussions with service users and staff, however these reports had not been completed on a monthly basis as required. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 20 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 3 x Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 21 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 9 Regulation 13(2) Requirement Timescale for action 24/10/05 2 9 13(2) 3 9 13(2) 4 9 13(2) 5 9 13(2) There must not be gaps in medication administration records. Records must either be signed or a relevant code used. (Informed at the time of the inspection) Where medication 24/10/05 administration records are hand written (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. (Informed at the time of the inspection) Medication administered must be 24/10/05 signed for at the time of administration. Controlled drugs must be recorded as administered at the time of administration. (Informed at the time of the inspection) The controlled drugs balance of 24/10/05 medication remaining must be checked after every administration. (Informed at the time of the inspection) There must be a lockable fridge 30/12/05 DS0000035728.V261158.R01.S.doc Version 5.0 Page 22 Thomas Colledge House Care Home 6 9 13(2) 7 12 16 (2) (m) (n) 8 9 18 37 18(1) (c (i) 26 to store medication requiring refrigeration . This fridge should not store food.(informed at the time of the inspection) Medication must not be used after the specified period stated on the pharmacy label. (Informed at the time of the inspection) All residents must be consulted concerning their social interests and their needs concerning stimulation. This may require one-to-one consultation. The results of any one-to-one consultation should be recorded. Action must be taken to try to meet any needs identified. This must include any needs identified concerning religious observance. Care staff must undertake protection of vulnerable adult training. There must be a report completed by the registered provider or person responsible for the service, on a monthly basis, concerning the conduct of the care home. 24/10/05 30/01/06 28/02/06 30/12/05 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 9 11 12 Good Practice Recommendations Residents where possible should sign that they have received medication for self-administration purposes. Written policies and procedures should be available in respect of handling death and dying. All activities and opportunities for stimulation should be recorded. DS0000035728.V261158.R01.S.doc Version 5.0 Page 23 Thomas Colledge House Care Home 4 15 The correct menu for the day should always be displayed. Thomas Colledge House Care Home DS0000035728.V261158.R01.S.doc Version 5.0 Page 24 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.V261158.R01.S.doc Version 5.0 Page 25 - 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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