Care Home: Collyhurst

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What the care home does well We found that all the people we spoke to were happy with the care and support they receive at Collyhurst. All people are assessed prior to them living at the home so that their needs can be identified and a decision can be made on whether these can be met.CollyhurstDS0000004206.V378807.R01.S.docVersion 5.2We observed good interaction between staff and the people who live at the home. People told us staff were kind and attentive to their needs. One person commented, “You only have to ask for something to be done and it’s done.” There is a wide range of activities on offer which include people coming in to the home to provide activities for people to take part in if they wish. People told us they enjoyed the various games and activities provided daily. One person commented, “There is always something to do.” People have confidence that a concern or complaint will be acted upon to their satisfaction. People find the management team approachable and staff told us that managers are supportive. We were told by a person, “I have never had anything to moan about here, and the staff are lovely they do anything for us". What has improved since the last inspection? Medication management has been reviewed and care records are clearer in demonstrating that people’s care needs are being met. This should promote the health and safety of people using the service. What the care home could do better: We consider the home to be performing well and provide positive outcomes for people who use the service. We have not issued any requirements following this visit. We have made some good practice recommendations that the service should consider implementing to improve the well being of people. The home should consider undertaking more frequent audits of the records relating to the management of medication so that it is clear people are receiving their medicines as prescribed by the GP to maintain their health. Where a person requires pureed food, the home should consider liquidising each food item separately. This will enable the person to taste each food item individually and enhance their enjoyment of the meal. Key inspection report CARE HOMES FOR OLDER PEOPLE Collyhurst 31-33 Nuneaton Road Collycroft Bedworth Warwickshire CV12 8AN Lead Inspector Patricia Flanaghan Key Unannounced Inspection 4th and 17th December 2009 10:30 DS0000004206.V378807.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Collyhurst DS0000004206.V378807.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Collyhurst Address 31-33 Nuneaton Road Collycroft Bedworth Warwickshire CV12 8AN 02476 319092 02476 319092 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) Mr K Taylor Mrs Elizabeth Taylor Mr Charles George Taylor Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Collyhurst DS0000004206.V378807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: old age, not falling within any other category OP 34 . The maximum number of service users to be accommodated is 34. 2. Date of last inspection 5th December 2008 Brief Description of the Service: Collyhurst Home is a family owned and run care home, which is situated in the Collycroft area of Bedworth. The home is registered to provide care for the older person and one younger adult with specialist needs. Collyhurst is located on the main road, which links to the two towns of Nuneaton and Bedworth and is very convenient for local services, hairdressers and shops, and a community centre, which is within close walking distance. Accommodation is provided both in the main building and a small bungalow, which is situated to the rear of the property. The bedrooms in the main house are accessible via a passenger lift or stairs. The home has been extended and new facilities include a car park, additional bedrooms and bathrooms and an eighteen person passenger lift. The bungalow has it’s own small kitchen and lounge facility and accommodates up to four people. There are pleasant garden areas at the rear of the home, which are accessible to the people who live at Collyhurst. People should contact the service for information about the fees it charges for residency. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience Good quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live in the home 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. This unannounced inspection took place over two days and lasted eight hours in total. Two people who were staying at the home were ‘case tracked’. The case tracking process involves establishing an individual’s experience of staying at the home, meeting or observing them, discussing their care with staff and relatives (where possible), looking at their care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. A completed Annual Quality Assurance Assessment (AQAA) was received from the service prior to the inspection detailing information about the care and services provided. Information contained within this document has been included within this report where appropriate. A range of evidence was used to make judgements about this service to include discussions with people using the service, visitors, the registered manager, deputy and staff. We also examined a number of records including care records of people living at the home, staff training, staff recruitment, complaints records and health and safety records. A period of time was spent in the communal areas of the home to observe what it may be like for people living in the home. A tour of the home was undertaken to view specific areas and establish the layout and décor of the building. What the service does well: We found that all the people we spoke to were happy with the care and support they receive at Collyhurst. All people are assessed prior to them living at the home so that their needs can be identified and a decision can be made on whether these can be met. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.2 Page 6 We observed good interaction between staff and the people who live at the home. People told us staff were kind and attentive to their needs. One person commented, “You only have to ask for something to be done and it’s done.” There is a wide range of activities on offer which include people coming in to the home to provide activities for people to take part in if they wish. People told us they enjoyed the various games and activities provided daily. One person commented, “There is always something to do.” People have confidence that a concern or complaint will be acted upon to their satisfaction. People find the management team approachable and staff told us that managers are supportive. We were told by a person, “I have never had anything to moan about here, and the staff are lovely they do anything for us. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.2 Page 7 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 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 Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the service experience good quality outcomes in this area. People have access to written information about the home to help them make an informed decision on whether to live at Collyhurst. An assessment of people’s needs is carried out prior to them moving in to the home to ensure these needs can be met effectively. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a Service User Guide containing detailed information about the home which is given out to prospective residents or their representatives. This is in large print so that people with poor eyesight can view the contents clearly. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 10 Information supplied in the AQAA told us that the home; “undertake a full assessment before service users are admitted to ensure we can cater for their individual needs.” We discussed the pre-assessment process with the manager. The manager said this assessment is always carried out by two people, usually himself with a member of the management team. They visit the person in their own home or in hospital as appropriate. This assessment ensures the needs of people are identified so that a decision can be made whether the home can meet these needs. We looked at the care files belonging to a recently admitted person. Copies of the pre-assessment records were available to confirm these assessments had been carried out. Information obtained at the assessment stage had been transferred into care plan records to ensure staff support to meet these needs could be arranged. We spoke with the person and their relative who confirmed that the manager had visited the person in hospital to discuss their care needs. The relative told us that they had “visited three or four care homes, but Collyhurst was by far the best.” Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. People living in the home are well cared for and each person has a detailed care plan to ensure their needs are identified and can be met by staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We assessed how peoples health and personal care needs are met. Information in the AQAA completed by the manager told us that, “All residents have their own individual care plans consisting of risk assessments for nutrition, moving and handling, pressure sores and falls.” We looked at the care plans for the two people who were followed through the case tracking process. Each person had a care plan, which identified the person’s care needs based on their activities of daily living. The plans of care are based on the initial pre-admission assessment of people’s needs and a Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 12 further admission assessment is carried out when they are admitted to the home. These include for example personal care, eating and drinking, spiritual, socialising, mobility and health promotion. Risk assessment tools available and completed for these people included identifying the level of risk for people in relation to falls, nutrition, mobility and moving and handling. Risk assessments had also been completed related to the risk of people developing skin wounds due to pressure area damage. When the outcome of the assessment identifies an increased risk, action is implemented to minimise the risk. This should promote peoples well being. For example, one person was identified as having a high risk of falls. A care plan was available to support their mobility including action to be taken to minimise the risk of falls. There was evidence that people are seen by external health care professionals such as the GP, dentist, optician and people are assisted to attend hospital appointments. This ensures that people receive specialist advice and that their care needs are met. People were well presented and were supported by staff to choose clothing that reflected individual choices. We observed people to be treated with respect, with their dignity and privacy being maintained. One relative commented on how kind and caring the staff group are. They provided us with their own experience of observing staff being respectful to people who live in the home. The staff group were patient, kind and caring throughout the inspection visit. People we chatted with confirmed this is the case at all times. We spoke with three care staff. They were familiar with peoples needs and abilities, and knew what care they needed. A visitor spoken with told us that they were very happy with the care their relative receives. They told us that their healthcare needs are met and that the home keeps them in touch with important information about their relative. They were very complimentary about the staff and management of the home. A review of medications was undertaken and these were found to be managed well. It was evident improvements had been made following the last inspection. Staff at the home have received training in the safe administration of medication. The home has a small medication room, medication trolley, medication fridge and a cupboard to store all medication appropriately. The medication trolley is used to transport the medicines throughout the home. It was clean and well organised making it easier for staff to select the correct medication. Surplus medicines were stored in a separate locked cupboard which was also clean and well organised. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 13 All the prescriptions are seen prior to dispensing and copies of these were seen. These are used to check the medicines and MAR charts received into the home for accuracy. The majority of medicines were dispensed in a Monitored dosage system whereby each tablet is dispensed in a blister pack for each day. Other medications were in individually named boxes. The amount of medication received at the beginning of the medication cycle was clearly indicated on the medication charts so that it was clear how much medication each person had at the beginning of the medication cycle. We checked the medication for the two people we cased tracked. These mediations were accurate in respect of the amount given and remaining. We looked at the medication for a third person. When we checked the amount of tablets in stock against the administration records we found there was one tablet short. This could mean that on one occasion the person received more tablets than they should have. The home has a quality assurance system to assess staff competence in their handling of medication. Regular audits are undertaken to check the MAR chart to see if staff had recorded exactly what had occurred and action is immediately taken if any discrepancies are seen. Regular audits are also carried out by the community pharmacist to confirm staff are working to the homes polices and procedures. We checked the controlled drugs and saw that they were securely stored and accurate records kept. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience excellent quality outcomes in this area. People have access to social activities and are able to exercise choices regarding their care and meals to maintain their independence and wellbeing. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We were told in the AQAA the home “encourage residents into the community by visits to hairdressers, parks, library, shopping trips and pubs. We provide an activities programme for residents who wish to participate” The home has an activity co-ordinator who works flexible hours including evenings and weekends. She told us about activities that take place on a regular basis, such as arts and crafts, basketball, hoopla, bingo, quizzes and flower arranging. The people living at the home decide what activities they would like to do each week. Records in the home confirmed which activities each person had participated in. The co-ordinator said that social activities are provided every day although some people were happy to observe rather than Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 15 join in. We saw a bingo session and hoop-la game taking place during the inspection. It was evident that these sessions were greatly enjoyed by people, both those participating and those who choose to sit and watch. We saw that the home is participating in a study called OPERA (Older Peoples Exercise intervention in Residential & Nursing Accommodation), funded by the Department of Health and organised by University of Warwick. This is a study of the how exercise and social interaction can impact on the well being of people living in care homes. The work consists of training for the staff backed up with twice weekly physiotherapist led exercise classes. The staff and people living at Collyhurst were very enthusiastic about the programme. One of the people we case tracked was actively involved in the programme and the exercise classes had improved their mobility to a degree that they were able to walk unaided, where previously they required a walking aid. People told us: “There’s always something to do.” “Now, with Christmas coming up there is a great atmosphere here, we are all looking forward to the Christmas party.” “The activity coordinator is brilliant, she is so enthusiastic, my relative looks forward to the games and bingo, although sometimes she is content to sit and watch.” People we case tracked and other people we spoke with during our visit told us that their daily routines are flexible and they are able to choose how they wish to spend their day. Individuals told us that their family and friends could visit at any time. The home has an open visiting policy, although visitors are politely requested to refrain from visiting at mealtimes so people are not disturbed during their meals. We noted that one person has a relative join them for lunch several times a week. This means that people can see their visitors as they chose and maintain relationships that are important to them. We spoke with two visitors who said they were made welcome when they visit. Comments included: “I am always made very welcome when visiting.” “It is always a pleasure to visit. I’m offered a cup of tea and I have a chat with the staff.” There are arrangements in place for people to receive religious services within the home and their spiritual needs are recorded on their care files. There are three dining rooms in the home. We observed the mid day meal in the main dining room. Tables were set with table cloths, napkins, glasses, Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 16 condiments and cutlery. Mealtimes are seen as a social occasion in the home and people were seen chatting to each other while they were having their meal. This ensures people have an enjoyable eating experience and helps to maintain their appetite. Lunch on the day of the visit was beef with mixed vegetables or cheese and potato pie. Meals were well presented and appetising. Staff were seen to assist some people to eat in a sensitive manner and without rushing them. We saw a person being assisted to eat a meal which had been pureed together rather than each individual food item being pureed separately. This prevents the person from being able to taste each food item individually to enhance their enjoyment of the meal and also prevents the meal from looking appetising. We discussed this with the manager who agreed to review this process. Drinks are available throughout the day, for example, tea, coffee and cold drinks. We briefly viewed the kitchen and saw it was clean and organised. Good stocks of food were available in the fridges, freezers and storage areas. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. People can be confident that any complaints or allegations of suspected abuse are taken seriously and managed appropriately. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints procedure is clearly displayed throughout the home and is available in large print, this enables those people with poor eye sight to read the information on how to make a complaint. The home keeps a record of complaints made and the actions taken in response to them are fully recorded. The manager has a very positive attitude to complaints, and said they are pleased to hear from people, to be able to put things right if there are problems. People told us they know how to complain and staff always listen to them if they have any concerns. For example, we were told, “Complain? What’s there to complain about, you couldn’t find a better home or nicer people to run it.” Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 18 “I’ve never had to complain, but I know if I had any concerns about my relative the manager or deputy would put it right straight away.” “You can speak to any of the girls, they are all equally as good.” “I have never had anything to moan about here, the staff are lovely they would do anything for you.” All staff spoken with indicated they were aware of the homes complaints procedure. The home has a safeguarding policy to give staff direction in how to respond to suspicion, allegations or incidences of abuse. The training matrix shows staff have received training about safeguarding people and know how to respond in the event of an incident of suspected abuse. Staff spoken with were able to give satisfactory responses to questions about how to keep people safe. They were able to tell us about the different types of abuse and what they would do if an allegation was made to them. A Whistleblowing Policy is in place which sets out information about what staff can expect should they report an allegation of abuse. It was evident through discussion with the manager that he is aware of his responsibilities in responding to allegations of abuse and discussed with us the procedure for referring allegations for investigation under local Adult Safeguarding Procedures. A visitor told us, “I know my relative is safe here.” Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 People using the service experience good quality outcomes in this area. People live in a well maintained home that is homely, clean and hygienic. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager showed us around the home. We saw it was clean and comfortable. The furniture and fittings are of a good standard and communal areas are pleasantly decorated. Corridors are wide and spacious and enable people to move around the home using any aids they may require. We looked at several bedrooms. We saw rooms that were full of personal possessions reflecting the persons life and family We spoke with a person Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 20 who was relaxing in their bedroom who told us, “My room is clean, warm and comfortable, I’m very happy here.” The manager has told us in the AQAA that there is an ongoing redecoration and refurbishment plan for communal areas and bedrooms and the replacement of furniture as necessary. All the bathrooms and toilets had adapted facilities including raised toilet seats grab rails, and a bath hoist. There are two passenger lifts to the first floor. The home has systems in place for the management of dirty laundry and the clothes of everyone living in the home looked clean, ironed and well looked after. The manager showed us his plans to increase the laundry provision in the home by installing a laundry room on the first floor. There are also facilities available for people to do their own laundry should they wish to remain independent. We observed staff using good hygiene practices. When we spoke with staff they were aware of good infection control practices, and confirmed they had adequate supplies of gloves, aprons, soap, and towels. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. There are sufficient staff who are appropriately trained and recruited to meet people’s needs and keep them safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a very stable staff team with some staff having worked in the home for a considerable number of years. They have built up good relationships with the people who live at the home and amongst themselves, which contributes to the good atmosphere in the home. The manager does not use agency staff, and is able to cover shifts from within the staff team. This means that people know who will be supporting them with their needs. It was evident from the general appearance of people living in the home and observation of working practices that there are sufficient staff on duty to meet their personal care needs. People using the service told us, Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 22 “Staff look after us and give us a lot of support.” “I don’t where I’d be if it wasn’t for the kindness of the staff here. They tend to our every need.” New staff receive an induction into the home and then work through the ‘Skills For Care’ induction which is more in depth. This should mean that staff are knowledgeable about their role. The personnel files of a recently recruited staff member was examined to assess the recruitment procedure. We saw evidence that a Criminal Record Bureau (CRB), satisfactory Protection of Vulnerable Adult (PoVA First) checks and satisfactory references were obtained before new staff members started working in the home. These robust recruitment practices should safeguard people living in the home from the possibility of abuse. The home has a training matrix, which is updated with the training that staff have undertaken to increase their knowledge and skills. Training includes various topics such as fire, first aid, moving and handling, safeguarding adults, infection control, nutrition and dementia. Copies of training certificates were seen in the staff files we reviewed. The manager told us in the AQAA that 95 of staff have a national vocational qualification in care (NVQ). This should mean staff have the necessary skills to provide a good level of care to people living at Collyhurst. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. The care home is managed in the best interests of the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Colyhurst is a family run business. The registered manager and deputy manager are husband and wife and the parents of the registered manager are the owners of the home. The manager has many years experience of caring for older people and in a managers role. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 24 The manager completes training courses to keep his knowledge up to date. This should ensure that he has the knowledge to support staff and ensure the home is run in the best interests of the people who live there. Before the inspection the manager had completed the Annual Quality Assurance Assessment (AQAA). This gave us information about how the home thought they were performing, what they do well and how they could improve. The manager had identified areas where improvements could be made and had plans how to achieve this. The information in the AQAA was consistent with our findings on the day of our visit. People living at the home are regularly consulted in what they think about the service and any improvements that could be made, although when asked nobody thought the home could be improved in any way and were happy with the service. Comments made by people included: “I like it the way it is.” “Well, nothing really, I’m quite happy here.” There are regular internal audits carried out by the manager and deputy,for example medication, care plans and room audits. This forms part of the quality assurance system and ensures that standards are regularly monitored. The home is able to hold small amounts of personal money for people. Each person has an individual record and receipts are kept which matched the entries made. All of the money we audited was correct and this means that peoples money is held safely. All checks required such the fire safety systems, hot water systems, lifting equipment and electricity are in place. People are protected through regular maintenance of systems and equipment and records to show this are well organised. For example we saw that portable appliances and the lifts, hoists and assisted baths had professionally checked in the last three months. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 26 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations Robust audit systems should be in place to confirm that people are receiving the correct dose of medication to promote their health and wellbeing. It is recommended that pureed foods are presented separately to enhance people’s appreciation and enjoyment of their meals. 2 OP15 Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 27 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Collyhurst DS0000004206.V378807.R01.S.doc Version 5.3 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!