Care Home: Colne Place

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What the care home does well Relatives told us they were generally happy with the service and care provided, they particularly expressed they could approach the manager at any time with any concerns they may have and be confident they would be dealt with appropriately. Relatives told us "Very satisfied, co-operative and helpful staff. The home is always very clean and the food is good", "I visit at various times unannounced, there has never been a time when I have found X unkempt or looking uncared for", "I always come away feeling that x looks clean and well" and "Never anything to worry about". The staff members demonstrated good knowledge of how each person preferred to be cared for and supported. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 What has improved since the last inspection? The previous inspection of this service resulted in a requirement for each person to be issued with a contract setting out their terms and conditions of residence and current fees whether they are privately funded or funded through social services. Files we looked at during this visit confirmed this had been done. There was a further requirement for records to be maintained of any accident or incident which is detrimental or affects the health, safety or well being of people living at the home. Evidence was available to show that this requirement has been met. A recommendation of good practice was made to avoid mistakes with people`s identity that each persons Medication Administration Record (MAR) chart had a front page with their name and photograph. Scrutiny of MAR charts showed us that this had been done. What the care home could do better: This inspection identified that actions had not been taken in response to requirements made in the previous inspection report in 2008. This has resulted in a number of repeat requirements which, whilst not impacting on the outcomes for individuals at this stage, must be addressed or we will have no option but to take further action. Whilst residents and relatives are generally happy, there is much work to do in order to bring the service up to the required standards. Some shortfalls in the administration of medication need to be addressed to ensure the safety and well being of the residents. More detail is needed in the pre-admission assessments, the care plans and daily records in order to be sure that each person`s needs are met in the manner they choose. Regular reviews of care plans need to take place to be sure that peoples` changing needs are identified and planned for. Relatives told us "The only thing I would say is that I wish staff would wear name badges. You don`t know who to speak to, it would be very helpful for visitors".Colne PlaceDS0000017797.V375988.R01.S.docVersion 5.2The social activities programme for residents needs development to ensure that it meets everyone`s needs and provides stimulation and interest for people. The staff training provision has some gaps and this needs to be addressed along with providing staff with an adequate supervision system in order to ensure the safety and welfare of people living at Colne Place. The management of complaints, including staff awareness, needs improving to ensure people are listened to and taken seriously. Records of complaints can give the management a more objective overview of the quality of the service they are providing for people. Staff recruitment processes need to be tightened up to ensure, as far as possible, that residents are protected. The premises require some routine work and refurbishment, in particular the bathrooms need attention to make them pleasing places for people to use. Key inspection report CARE HOMES FOR OLDER PEOPLE Colne Place 97 High Street Earls Colne Colchester Essex CO6 2RB Lead Inspector Jane Greaves Key Unannounced Inspection 15th June 2009 09:15a DS0000017797.V375988.R01.S.do c Version 5.2 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. Colne Place DS0000017797.V375988.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 Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colne Place Address 97 High Street Earls Colne Colchester Essex CO6 2RB 01787 222314 01787 223984 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) Handsale Limited Mrs Maria Connolly Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th July 2008 Brief Description of the Service: Colne Place is a residential care home for the elderly set in a period residence with large well-maintained grounds over looking the village church. The premises have been extended and provide accommodation and 24-hour care to 33 people, with varying levels of dependency. The accommodation is mainly in single rooms many of which have en suite facilities. All parts of the home are fully equipped to provide a safe environment for those with restricted mobility. The fees range from £444.57 - £465.00 per week. Items considered to be extra to the fees include chiropody, toiletries, hairdressing and newspapers. This was the information provided at the time of key inspection, people considering moving to this home may wish to obtain more up to date information from the care home. Inspection reports are available from the home and our website at www.CQC.org.uk Colne Place DS0000017797.V375988.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 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key site visit that took place over 7 hours. At this visit we considered how well the home meets the needs of the people living there and how staff and management support people. A tour of the premises was undertaken, care records, staff records, medication records and other documents were assessed. Time was spent talking to, observing and interacting with people living at the home, visitors and staff. Prior to the site visit the manager had completed and sent us the homes Annual Quality Assurance Assessment (AQAA). This is a self assessment document required by law and tells us how the service feels they are meeting the needs of the people living at the home and how they can evidence this. Views expressed by visitors to the home during the site visit and in survey responses have been incorporated into this report. Feedback on findings was provided to the manager throughout the inspection and the opportunity for discussion and clarification was given. We would like to thank the residents, the manager, the staff team and visitors for the help and co-operation throughout this inspection process. What the service does well: Relatives told us they were generally happy with the service and care provided, they particularly expressed they could approach the manager at any time with any concerns they may have and be confident they would be dealt with appropriately. Relatives told us “Very satisfied, co-operative and helpful staff. The home is always very clean and the food is good”, “I visit at various times unannounced, there has never been a time when I have found X unkempt or looking uncared for”, “I always come away feeling that x looks clean and well” and “Never anything to worry about”. The staff members demonstrated good knowledge of how each person preferred to be cared for and supported. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: This inspection identified that actions had not been taken in response to requirements made in the previous inspection report in 2008. This has resulted in a number of repeat requirements which, whilst not impacting on the outcomes for individuals at this stage, must be addressed or we will have no option but to take further action. Whilst residents and relatives are generally happy, there is much work to do in order to bring the service up to the required standards. Some shortfalls in the administration of medication need to be addressed to ensure the safety and well being of the residents. More detail is needed in the pre-admission assessments, the care plans and daily records in order to be sure that each person’s needs are met in the manner they choose. Regular reviews of care plans need to take place to be sure that peoples’ changing needs are identified and planned for. Relatives told us “The only thing I would say is that I wish staff would wear name badges. You don’t know who to speak to, it would be very helpful for visitors”. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 7 The social activities programme for residents needs development to ensure that it meets everyones needs and provides stimulation and interest for people. The staff training provision has some gaps and this needs to be addressed along with providing staff with an adequate supervision system in order to ensure the safety and welfare of people living at Colne Place. The management of complaints, including staff awareness, needs improving to ensure people are listened to and taken seriously. Records of complaints can give the management a more objective overview of the quality of the service they are providing for people. Staff recruitment processes need to be tightened up to ensure, as far as possible, that residents are protected. The premises require some routine work and refurbishment, in particular the bathrooms need attention to make them pleasing places for people to use. 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. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People considering moving into Colne Place have an assessment of their needs undertaken. There may not be sufficient detail obtained about their individual needs for staff to be able to provide person centred care. EVIDENCE: An up to date Service User’s Guide was available, the guide contained all the information people would need to help them make an informed decision about whether Colne Place was the right home for them. To ensure that people have access to good information to help them make decisions the Service Users Guide should be properly developed in a format suitable to meet the needs of all people who might use the service, such as people with visual or other Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 10 sensory impairments. This had been identified at the previous inspection of this service and discussed with the manager at this visit. The pre admission assessment documentation had been reviewed since the previous visit. The assessment covered various areas of need including mobility, orientation, breathing, communication, eating and drinking, personal care and hygiene, tissue viability, social interaction and sleeping. We looked at a pre admission assessment of needs for one person recently admitted to the home. The recorded information was brief including little detail about how support needed to be provided. For example one pre admission assessment we looked at stated ‘needs two people to transfer’ and ‘Needs help with all personal care’. This information is very basic and doesn’t provide staff with detail about how the person prefers and needs support in order to keep them as comfortable and safe as possible whilst promoting their dignity and encouraging their independence. We spoke with relatives of a person that had recently moved into the home. They told us they were confident that the home was meeting the needs of their relative they said “There were some teething problems to start with but now they know X it has settled down nicely”. The manager’s AQAA stated under ‘our plans for improvement’: To carry on improving pre-assessments and ensure residents’ needs can be met. Encourage staff and residents to welcome new residents and make their move into the home as successful as possible. We looked at documents for three people living at the home. Two of these included a contract setting out the terms, conditions and fees for the people living at the home. The file for a recent admission did not contain a contract; the manager reported that this had not yet been returned by the person’s family. Colne Place does not offer intermediate care. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive good care but cannot be sure it is based on their individual needs and wishes. People are not protected by medication practices in the home. EVIDENCE: During discussion with people living at the home and visitors during this site visit people said they felt that they received suitable care. People appeared well cared for. Discussion and observation showed that staff were attentive to peoples’ needs and had a good awareness of individuals’ requirements. The home is small with an established core group of care staff. Many staff had worked there for a number of years and knew the residents very well. We looked at three peoples’ care plans at this visit. The plans detailed that people needed support with personal hygiene however these did not contain sufficient information of how the person wanted and needed to be supported and lacked a consistent, detailed and person centred approach. Staff Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 12 demonstrated to us that they knew people well and instinctively provided the care people needed however this was not documented. Care records showed us that people were supported to access different health care professionals such as opticians, district nurses and others necessary to meet their needs. Daily recording was brief and did not provide detail to confirm that care and support was delivered in accordance with the plan of care. Examples included: ‘X is fine, down for meals”, “X is fine today, spent some time in garden room” and “assisted to wash, dress and get up”. This recording did not contain enough detail to describe the person’s demeanour, what they had done with their day and did not provide enough information to ensure accurate and effective care plan reviews could take place. The service did not operate a key worker system, the manager and deputy undertook the care plans reviews. They reported that staff interaction, personal observation together with information from daily records informed these reviews. Peoples’ care plans contained evidence to show us there were planned routine monthly reviews, however, on one file we sampled at this visit there had been 3 reviews in the past 6 months. This means that some changes in peoples’ needs may not be identified and their care plans amended accordingly to meet those needs. When amendments to the dependency assessments were identified these did not always lead into amendments of the care plan. For example one person’s cognitive abilities had waned over months, this had been identified through dependency assessment however there was no evidence to show that risks had been re-assessed due to lack of cognition. There was nothing in the care plan to show that the person’s care and support needs had been re-assessed as a result of these changes. Care plans included a weight monitoring chart to be completed monthly. On one of the three files we looked at the person’s weight had only been recorded twice this year. This means that there is a risk that patterns of weight loss or gains may not be identified and therefore underlying health problems may not be identified in a timely manner. Peoples’ care plans were stored in a cabinet by the care station. The cabinet was locked with a combination padlock so that staff could easily access them when needed but peoples’ privacy and dignity was protected. During the day staff members were seen to be kind and caring in their approach to residents. Discussion with members of the care team showed us that they had a good understanding of peoples rights and the need to preserve peoples privacy and dignity. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 13 Relatives told us “I always come away feeling that x looks clean and well” and “Never anything to worry about” and “I visit at various times unannounced, there has never been a time when I have found X unkempt or looking uncared for” At the previous inspection visit to this service a requirement was made for suitable adaptations and equipment to be provided for people who were old, infirm or physically disabled, which have been assessed by a suitably qualified person. This was so that each person using the service was provided with equipment to meet their individual needs. This had not been done, the manager and deputy reported they had made frequent requests from the local services for this support but had not been successful. An example given was one resident was referred for a wheelchair however; the wheelchair clinic refused the referral saying that the home had ‘pool’ chairs for the person to use. The pool chairs were not suitable due to height and weight issues. The family purchased a chair independently so their relative would be safe and comfortable. We arrived at the home at 09:15 hours, our arrival was not noted and we were able to wander freely in the home. We observed the medication trolley was in the small dining area, it was open and unattended and two blister packs of medication were on the dining table. This is not safe practice, there were residents up and about at this time, some of whom are, by nature of their condition, confused and may take medication not prescribed for them. We looked at Medication Administration Records (MARs), these showed us there were some gaps in recording when medications were given or refused by residents. This meant that it was not always possible to confirm if people had received their medication or who had dispensed it to them. The MARs included a photograph of individual residents in order to avoid mistakes with peoples’ identity when administering medication. The deputy manager reported attending a pharmacy led medication course, receiving advice from the home’s pharmacy supplier and receiving an annual audit from the pharmacy. Evidence was produced to confirm a pharmacy audit had taken place in October 2007; there was no evidence to say there had been a further audit since then. Staff training records and discussion with the manager showed us there were three staff that had not received medication training that were responsible for “giving the odd ones out on night duty”. The manager’s AQAA stated ‘All medication records are up to date’ and ‘Staff training is in place and up to date for all staff’. This did not concur with our findings at this visit. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to welcome their families and friends, however may not have sufficient opportunities for activity and stimulation. EVIDENCE: The home no longer had a full time activities co-ordinator to provide and organise activities for the residents, the manager told us that afternoon care staff take on this responsibility. The manager reported ‘difficulty in motivating people towards activities and past times’. Records told us that people participated in activities such as quizzes and poetry reading, discussion (for example, Government changes since residents’ younger days) outings with friends, Church services, Bingo, Mother’s union, and musical entertainers were brought in from outside the home to entertain people regularly. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 15 A staff member told us how she had encouraged residents to become involved in playing Lexicon some afternoons. She reported that it created a competitive atmosphere and became a spirited occasion. The Activity Schedule told us that people were provided with the opportunity to take part in card making, afternoon tea in the garden, Bingo, Lexicon and attend church services. The weekly hairdresser visit was classed as an activity. There were no activities scheduled for the weekends. There were no activities taking part at the home on the day of this visit. During the morning we noted 5 people sitting in total silence in the front lounge, just staring around them. During a 40 minute period one staff member came in once, spoke to one of the residents and left the room again. During the afternoon the same 5 people were noted sitting in the front lounge. The television was on but no-one was watching it. People appeared fed up, disinterested in their surroundings and withdrawn. The front lounge is situated away from the busier areas of the house and staff need to ensure that people are not isolated in this way. People told us “TV doesn’t interest me I am afraid” and “It is very dull here; it will be yet another quiet afternoon” and “I look out of the window, sometimes I go out”. The manager’s AQAA stated ‘Activities within the home are organised around the needs of residents within the home. We encourage residents to organise which activities that they can attend’. We did not see any evidence of individualised activity provision or staff spending time engaging with people. Visitors came and went during the course of the day, we noted they were welcomed by staff and that family pets were encouraged to visit also. We observed people enjoying accessing the grounds independently where they were able. People we spoke with had mixed views about the food and drinks provided at the home, comments included: “The food, I am not keen on it at all – same old stodge, I leave most of mine. One good day a week is Friday, fish and chips is good!”, “You don’t get a morning cuppa like you used to at 7am, often much later now, you have to wait”, “Food is excellent” and “Food’s not bad at all, can’t complain, it’s edible, mustn’t grumble”. We looked at the menu, this showed us that there was a good range of meals with two choices of main meal each day, with the exception of Thursdays and Sundays where a roast dinner was provided, however the chef confirmed if someone did not want a roast an alternative would be offered. The deputy manager told us that one resident had opted to have their main meal in the evening and has a late cooked breakfast; this was a good example of person centred support. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 16 The kitchen was clean and well organised and had recently been rated as 4* by the environmental health dept. The Cook had advised the provider that one fridge needed to be replaced, the front grill was broken and the shelves were rusting with paint peeling off. The fire officer had also requested that this fridge be moved as it was placed in a recess by a door way and could pose a hazard to safe evacuation. The cook was not able to tell us if the provider was replacing the fridge or where it would be re-positioned. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were confident that any complaints are dealt with, but cannot be assured that staff have the training to support people with behaviours that can be challenging to others. EVIDENCE: The service had policies and procedures in place to enable people to make complaints or raise concerns about the service provided at Colne Place. The previous inspection report for this service included a recommendation that consideration should be given to producing information about the home and how to make a complaint available in a format suitable for people with impaired vision. The manager reported that this would be made available in larger print however no progress had been made towards this at this time. It would benefit people using the service and their relatives if all information about the home was readily available to access at will without having to ask a member of staff first. The manager’s AQAA stated: ‘The manager deals with any complaints or concerns as soon as they are made. We hope to resolve any problems that arise smoothly so that the home can run efficiently. Residents and relatives or visitors to the home seem confident to come to the manager and senior staff with any problems that they may have.’ Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 18 Visitors told us they were confident to take any concerns that arose to the staff or management at the home and equally confident they would be dealt with expediently. Records showed us there had been no complaints received by the home in the past 12 months. Staff told us that if anyone has an issue to raise it is dealt with immediately and therefore doesn’t become a ‘complaint’. This shows us that the service was reactive as opposed to proactive with regards to dealing with complaints. What were perceived to be ‘minor’ issues that were dealt with immediately were not recorded as complaints and therefore the opportunities to identify trends and patterns of shortfall were not able to be identified. The previous inspection of this service resulted in a requirement for training to be provided and plans developed with strategies of how staff manage physical and/or verbal aggression. This was to ensure staff had the skills and knowledge to manage and understand behaviours challenging to others, and which safeguard the individual and others living and working in the home. This had not taken place at this visit; the manager booked this training on this day. Staff training records showed us that 6 of the 31 people employed to work at the home had not yet received training/refresher training in safeguarding vulnerable adults Staff told us that in they event they suspected any abusive practice they would report it to their manager. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 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, 21, 22, and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall Colne Place provides a homely environment for people however maintenance is not proactive and bathrooms are stark and basic. EVIDENCE: We undertook a complete tour of the home as part of this inspection site visit. The home appeared clean with no offensive aromas present. We noted in the back lounge that there was one call bell for entire room, and the lead was hooked up, not reachable by residents. The manager told us that people do not know what to do with the cords and that people will press the alarm on the wall if help is needed. There were no call bell leads at all in the Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 20 front lounge. Two previous requirements have been made in respect of this matter. Some rooms we saw were very personalised and reflected the personality of the people living in them; one bedroom we saw had curtains hanging from the rail because of missing and broken hooks. There was fraying carpet in an upstairs corridor, this did not constitute a safety hazard at this time however was unsightly. In one bathroom there were bare floorboards and a vacuum cleaner was stored there. The manager reported this facility was not in use at this time as they were waiting for a new bath hoist. Bathroom facilities were generally basic and stark, not attractive or homely places. Bathroom 2 on the ground floor had paint peeling off the pipe work, the door frames were badly battered by wheelchairs and shelves were used to store a stock of incontinence pads. There were ‘Boots Essentials’ Crème bath, shampoo, conditioner, shower crème and men’s shaving toiletries on a shelf in this bathroom. The manager reported that these were for communal use. People did not have their own toiletries and therefore had no choice of brand or fragrances. Two more bathrooms were noted to contain toiletries for communal use. We saw combs on the shelf in the bathroom; the manager reported that these were not for communal use and must have been left there by care staff on this day. We noted an upstairs toilet facility was used for storing unused furniture pieces such as a drawer unit and mirror. In one bedroom the en suite bathroom was used as a storage facility. We saw catheter bags, many incontinence pads, and an over bed table complete with salt and pepper pots. This person could not use the bathroom themselves however; this room was not usable by staff providing personal hygiene support or by the person’s visitors. Staff told us the passenger lift had been out of order for a couple of weeks prior to this visit meaning that residents were ‘stuck upstairs’ during that time. The manager told us the lift company had been waiting on parts for the lift hence the delay in repair. We noted a bolt on outside of one person’s bedroom door. The manager reported that this person had requested a bolt to prevent people entering the room in their absence. The manager acknowledged that a bolt on the outside of the door would not prevent anyone entering the room, however a lock and key would. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 21 The manager reported that whenever a room became vacant it was redecorated before a new person moved in. Improvement in the environment since the previous visit included new carpets in front hall, back lounge, drawing room, and one stairway, an en suite bathroom added and an existing en suite been amended to make it wheelchair friendly. The manager’s AQAA stated that the communal dining room was scheduled for refurbishment this year. At the previous inspection visit to this service a requirement was made for suitable adaptations and equipment to be provided for people who were old, infirm or physically disabled, which have been assessed by a suitably qualified person. These assessments had not taken place at the time of this visit; the manager reported attempts to secure professional assessments for people however these had not been successful. Training records showed us that 21 of the 31 people employed to work at Colne Place had attended Health and Safety training in April and May 2008, the remaining 10 staff had not attended this training. 7 staff had attended training in the Control of Substances Hazardous to Health (COSHH). People living at the home that we spoke with did not indicate a view about the environment, visitors told us “It’s generally clean enough” and “It’s homely I suppose”. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People received help and support from sufficient numbers of caring staff however they may not have all the training necessary to meet peoples’ needs. The recruitment practices are not consistently robust enough to ensure people are safely recruited to work with vulnerable people. EVIDENCE: We looked at the duty rota; this showed us that twenty-four hour care was provided for the people living at Colne Place. Staff told us, and scrutiny of duty rotas confirmed, that the minimum number of staff throughout the day was four care staff supported by a senior or the manager. Three staff, two awake and one sleeping in cover the nights. A chef, one kitchen assistant, a laundry assistant and three domestic staff provided additional support throughout the day. The home also employed a maintenance person and gardener. Staff confirmed staffing levels were sufficient to meet the needs of the people living in the home. Duty rotas had a number of amendments and crossings out which meant it was not always clear to ascertain who was on duty and for what period. The home employed total of twenty eight care staff; eighteen staff had completed NVQ Level 2 including the deputy manager (NVQ 3) and the Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 23 manager (NVQ 4). 4 care staff were working towards completion of this qualification. The deputy manager forwarded a copy of the training records to us subsequent to this visit. These showed us that whilst some gaps in the training provision remained in areas such as Safeguarding Vulnerable Adults (SoVA) and COSHH, the majority of the staff team had completed the basic core training necessary for them to be able to care for people safely. Records showed us that 6 of the 28 care staff had attended training to enhance their skills in looking after people with Dementia, the most recent of these was in May 2007. The deputy manager reported that a Dementia Awareness course had been booked for August 2009 however there was no detail as to how many staff were booked to attend this training. The previous inspection of this service resulted in a requirement for the staff team to be provided with training to give them the skills to manage challenging or difficult behaviours. This had not been provided at the time of this visit however, was subsequently booked for July 2009, no detail was provided about how many staff members would attend this training course. The manager told us that she does not have control of the home’s budgets. This means she was not able to plan the staff training schedule for the year ahead. The manager and deputy told us there had not been a staff meeting held since June 2008. We looked at staff recruitment documents for 2 recently recruited staff members. This was to assess if the relevant checks had been made to ensure people were cared for by safely recruited staff members suitable to work with vulnerable people. On one file we noted that the completed check made against the protection of Vulnerable Adults list had been received the day after a person had started to work at the home. The manager reported that she had confirmed that the person had clearance by telephone before the person started to work however this was not documented and therefore not confirmed. There were no professional references for this person; both references were from personal addresses, this does not provide evidence of the person’s previous employment performance or history. One file we looked at only had one completed and satisfactory reference response. The deputy manager said she was sure the completed reference had been received however it could not be found during this visit. This showed us that the service did not operate a rigorous recruitment procedure to ensure the safety and well being of the people living at the home. Relatives told us: “The only thing I would say is that I wish staff would wear name badges. You don’t know who to speak to, it would be very helpful for visitors” Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 24 Residents told us: “Some of the girls are very nice, they have been here a while” and “I’ve found the staff very nice” and “Very helpful staff”. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 25 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, 34, 35, 36, 37 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is run by a qualified manager; however the management needs to be more proactive to ensure the safety and protection of the people living there. EVIDENCE: The Manager’s AQAA told us: ‘The manager at Colne place has worked at the home for twenty two years. The manager is qualified to NVQ level 14 in management. The manager, in this time, has crated a residential home that is open, and positive with a homely atmosphere. The home has a positive culture that is inclusive of all those that are involved in it’s make up. The residents Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 26 benefit from this as it ensures that their best interests are maintained. All the residents’ financial interests are managed well and safely’. The manager sent their AQAA to us when we requested it. It contained limited information about the services provided at the home and any improvements that had been identified or brought about over the past 12 months. The AQAA did not tell us what actions had been taken to ensure the requirements and recommendations made at the previous inspection visit had been met. The manager had not sent us notifications as required under regulation. For example, death or events adversely affecting the well being or safety of people living at the home. The manager’s AQAA told us that 9 people had passed away at the home and one person in hospital in the 12 months previous to this visit. Staff told us the lift had been out of service for two weeks, residents had to stay in their upstairs rooms if they were unable to use the stairs. The manager was not sure if they ‘had any forms’ to report these incidents to us. The manager and deputy reported attending Mental Capacity Act and Deprivation of Liberty training. They said they felt it was not necessary to cascade this training through the staff team as they had no-one affected by this new legislation living at the home at this time. The deputy manager reported that the provider undertook responsibility for the Quality Assurance process, the last report was issued February 2008, there was no evidence available to confirm to us that this process had been undertaken since then. People we spoke with, including residents, relatives and staff could not recall any recent questionnaires about the quality of the service provision at Colne Place. The manager and deputy reported that the last visit to the home from the provider’s representative was approximately 2 months before this visit. The registered provider has the responsibility under regulation to visit the service monthly and inspect the premises, look at records and talk to residents and staff. The last of these reports available at the home was dated October 2005. Opportunity was given for the report to be submitted to be considered as part of this inspection process however it was not made available to us within appropriate timescales. The manager reported that finances for residents’ food or staff wages were not an issue however staff training, environmental issues and maintenance or equipment had to be requested from Head Office as she had no allocated budgets to work with. This meant she was not able to manage some areas of the service autonomously. The manager reported that staff training was the main area where she encountered difficulty however the service had recently secured a grant which would go towards staff training. An example of financial restrictions was given: At a fire appliance check on 01/06/09 it was identified that smoke detectors throughout the home should Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 27 be replaced, this had not yet been actioned. The manager reported that she had to wait for funds to be released from Head Office as the petty cash float was insufficient for this. We checked personal monies maintained by the manager for two people living at the home. Computer records were maintained showing peoples balances and where monies were paid out for items such as hairdressing and chiropody. The balances agreed with records with one error in recording where a hairdressing entry had not been made on the computer records. The monies were kept in the safe, accessible to the manager, her deputy and the cook. The manager’s AQAA stated under the ‘how we have improved’ in the staffing section that in the last year there had been ‘a supervision system set up’. In the management group section under the heading of ‘What we could do better’ the AQAA states: ‘Improve on staff supervisions, now have a good system in place but need to improve on the amount of supervisions that each staff member has within the year’. Staff files we looked at did not provide evidence of regular and effective supervision sessions; the deputy manager acknowledged this was an area for improvement necessary to bring practice in line with the homes policies and procedures that state 6 supervisions per year. We noted there was a policies and procedures file in the office and at the care station. The files were in no particular order meaning that it was not possible for staff to easily access guidance and as there were various versions of policies in the file they could not be sure they had up to date information should they need it. We looked at reports of incidents and accidents that occurred at the home, these included events such as people falling or rolling out of bed for example. These reports included good information describing the incidents however there was no indexing system in order for patterns and trends of events could be identified. For example the location or specific times of day of the falls, whether before or after meals or medication. Weekly and monthly routine safety checks are made in the home such as for water temperatures and call bells. The office sash window was faulty; it would not stay open on its own and had to be blocked open with a roll of sellotape. Some window restrictors were missing around the home. The manager was aware of this and said she thought it may have happened when decorators were painting the windows. We saw certificates to confirm that routine testing had taken place of such things as Electrical systems, Portable Electric Appliances, Fire extinguishers and passenger lifts. The result of the fire inspection in March 2009 was that the home was ‘not fully complying with legislation. This related to self closure devices on the Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 28 bedroom doors in the main house. This had not been actioned by the time of this visit. The funding had not come from the provider organisation Hansdale Limited. The manager reported that petty cash was not sufficient to cover the daily running of the home and to fund extra needs such as this. It was reported that the fire officer also requested that an upright fridge was moved from by a doorway as it was a potential hazard sited where it was. This has also not been actioned. This fridge was corroding inside and out and should be replaced. Staff and visitors told us that the management were open and approachable. Staff said “we have a very supportive manager, very caring and looks after us as well as the residents” Visitors confirmed they would be comfortable approaching the manager over any issue at all. Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 29 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 2 3 2 X X N/A 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 3 2 X 2 Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Peoples’ care plans must have a current assessment of their Needs. These must be reviewed and kept up to date. Timescale for action 15/09/09 2 OP9 13 This is so that residents can be assured that their care needs will be met in full in a way that they would wish. People must have their 15/07/09 medication administered, stored and recorded safely. This is to be sure their health needs will be met and they are kept safe. People should be provided with opportunity for social activities on an individual and group basis in a person centered way. 3 OP12 16 15/09/09 4 OP16 22 So that people are able to have a good social life in the home that promotes their independence and wellbeing. All complaints received, including 15/09/09 verbal complaints, must be logged and attended to as outlined in the DS0000017797.V375988.R01.S.doc Version 5.2 Page 31 Colne Place complaints procedure. So that residents and relatives can be assured that their concerns will be looked into. Suitable adaptations and equipment must be provided for people who are old, infirm or physically disabled, which have been assessed by a suitably qualified person. This will ensure each person using the service is provided with equipment, which will meet their individual needs. This is a repeat requirement with an original date for action of 31/08/08 No person shall be employed in the care home unless documents specified in paragraphs 1-7 of Schedule 2 have been obtained in respect of that person. This will ensure people living in the home are not at risk from staff that are unsuitable to work with vulnerable people. This is a repeat requirement with an original date for action of 31/08/08 Staff must be trained and competent to undertake the duties and responsibilities that they have. This is so that people are cared for by a skilled and competent staff team. An effective quality assurance system must be operated to ensure the views of people using the service and their representatives are used to improve the quality of the service provision. DS0000017797.V375988.R01.S.doc 5 OP22 23(2)(n) 15/09/09 6. OP29 19 (1)(b) Schedule 2 15/07/09 7 OP30 18 15/10/09 8 OP33 24 15/09/09 Colne Place Version 5.2 Page 32 9 OP33 26 10 OP38 37 The registered provider or his 15/07/09 representative needs to make available the report of the monthly visit to the home so that people can be confident that the quality of care and facilities are regularly monitored. The manager must notify the 15/07/09 commission of the death of any person living at the home, including the circumstances of the death and any event that adversely affects the safety or well being of people living at the home. This is to assure people that the health, safety and welfare of people living at the home is protected. 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 OP33 Good Practice Recommendations A copy of the most recent quality audit report should be forwarded to the CSCI. Supervision sessions should be undertaken at least six times a year. 2. OP38 Colne Place DS0000017797.V375988.R01.S.doc Version 5.2 Page 33 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@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. 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