Care Home: Coloma Court

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What the care home does well Adequate information was provided about the service for prospective residents and their family. Systems were in place to ensure residents healthcare needs were met. A part time physiotherapist was employed which helped residents to mobilise and helped staff with moving & handling assessments and difficulties. Varied and interesting activities were provided for residents. Staff treated residents with respect and dignity. The environment was well maintained, clean and comfortable. Satisfactory systems were in place to manage complaints, ensure safeguarding people and to manage resident`s personal allowances. Good staffing numbers were maintained. Recruitment procedures complied with regulation, staff received training relevant to their roles and care staff received formal supervision. Meetings were held with residents, relatives and staff and quality assurance systems were in place to review the service. The service was well managed and satisfactory systems in place to ensure a safe environment was provided for residents and others. What has improved since the last inspection? Residents receive written confirmation that based on assessment the service was suited to meeting their needs. Records in relation to wound management had improved. Most of the entries made by staff on medicine administration charts had been countersigned. Records were kept for the disposal of medicines Wardrobes in resident`s bedrooms had been secured. Staff rosters included the relevant information. Recruitment procedures had improved and files seen complied with regulation. A system was in place to provide care assistants with formal supervision. Risk assessments were completed prior to fitting bedrails. Records in relation to accidents to residents had improved. A larger mini-bus was provided for residents. From information provided in the AQAA other areas of improvement were for example the provision of 10 additional profiling beds, free-view boxes were provided to give residents a wider choice of television viewing and preadmission procedures included a visit for coffee or lunch and a taste of the activities provided What the care home could do better: Care plans must be prepared to show how all identified needs will be met. Risk assessments must be up to date and reflect the current needs of the person. Accurate records must be kept for all medicines brought into the home so that an audit trail can be completed, risk assessments in relation to residents wishing to manage their own medicines must be fully completed and supported by a care plan and the actual dose of a medicine administered must be recorded when a variable dose is prescribed. This report includes a number of recommendations, which the provider should consider implementing. CARE HOMES FOR OLDER PEOPLE Coloma Court Layhams Road West Wickham Kent BR4 9QJ Lead Inspector Pauline Lambe Unannounced Inspection 15th October 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coloma Court Address Layhams Road West Wickham Kent BR4 9QJ 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) 020 8776 1129 020 8776 1927 matron@colomacourt.org The Hospital Management Trust Maria Covington Care Home 62 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (52) of places Coloma Court DS0000067988.V366473.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 with nursing - Code N 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 - Code OP (maximum number of places: 52) Dementia - Code DE(E) (of the following age range: 65 years and over) (maximum number of places: 10) The maximum number of service users who can be accommodated is: 62 23rd October 2007 2. Date of last inspection Brief Description of the Service: Coloma Court opened in October 2006 and is a modern purpose-built threestorey building set in the grounds of the Daughters of Mary and Joseph’s estate in West Wickham. The registered care provider is The Hospital Management Trust. The home was built to a high specification, in line with regulation and to meet the needs of the people within its registration category. The home was registered to provide care for 52 older people requiring nursing care and 10 requiring dementia-nursing care. All bedrooms are for single occupancy with en-suite facilities and bedrooms and lounges have a view over the landscaped gardens or the countryside. Ample communal and storage space was provided and lounges situated so residents had pleasant views for the windows. Suitable bathing and toilet facilities were provided and fitted and decorated to a high standard. The property had two passenger lifts to enable residents to access all floors. The home is situated close to transport links and local shops and amenities. The current fees for the service ranged from £860.00 - £925.00 per week. Coloma Court DS0000067988.V366473.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 star. This means the people who use this service experience good quality outcomes. Two inspectors from the Commission completed this unannounced key inspection on 15th October 2008. The registered manager was in charge of the home and together with residents and staff assisted with the inspection. No changes to the registration of this service were made since the last inspection. The inspection process included a review of information held on the service file, a review of the information included in the comprehensively completed Annual Quality Assurance Assessment (AQAA), a tour of some of the premises, a review of records, spending time talking to residents, staff, visitors and management and reviewing compliance with previous requirements. Feedback surveys were received from a small number of staff and relatives and from 8 residents. Currently the Commission do not send surveys to relatives to obtain feedback on the service. The service was well managed, feedback received from residents and relatives showed they were satisfied with the care provided. The environment was well maintained and the manager and staff presented as committed to providing a caring and safe environment for residents. What the service does well: Adequate information was provided about the service for prospective residents and their family. Systems were in place to ensure residents healthcare needs were met. A part time physiotherapist was employed which helped residents to mobilise and helped staff with moving & handling assessments and difficulties. Varied and interesting activities were provided for residents. Staff treated residents with respect and dignity. The environment was well maintained, clean and comfortable. Satisfactory systems were in place to manage complaints, ensure safeguarding people and to manage resident’s personal allowances. Good staffing numbers were maintained. Recruitment procedures complied with regulation, staff received training relevant to their roles and care staff received formal supervision. Meetings were held with residents, relatives and staff and quality assurance systems were in place to review the service. The service was well managed and satisfactory systems in place to ensure a safe environment was provided for residents and others. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 4. Standard 6 does not apply. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Up to date and relevant information about the service was provided. Residents were admitted based on needs assessment and received written confirmation as to the suitability of the service to meet those needs. EVIDENCE: Since the last inspection the statement of purpose had been reviewed. A copy was given to the Commission and this complied with regulation. A very informative information pack was provided and a service user guide. Copies of the service user guide and information pack were seen in some resident’s bedrooms viewed. Five sets of care records were viewed and showed that residents were admitted to the home based on completion of a detailed pre-admission assessment. Some of the residents spoken with said they had been provided Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 9 with enough information about the home to make a decision about living there and some had visited the home or their relatives had done this on their behalf. Residents records viewed showed they had received written confirmation that based on assessment the home was suited to meeting their needs. The manager said that the home was very popular in the area and held a waiting list for admissions. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were prepared for residents and were kept under review. Systems were in place to ensure resident’s healthcare needs were met. Medicine management required some improvements. Residents were satisfied with the way staff respected their privacy. EVIDENCE: Inspectors spent time on all floors. Care records were viewed for five residents in total. As at the last inspection staff continued to work towards having all care records on the ‘Cool Blue’ computer system. Currently some paper and some computer records were kept and available to view. This presented some difficulties inspecting records particularly when reviewing wound management. However with staff assistance the records were viewed. Care plans seen included assessment of need, risk assessments and care plans. On the ground floor care records for one person were viewed. The resident was highly dependent and the care plans were up to date and relevant to the persons needs. However the moving and handling assessment had been Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 11 reviewed monthly but had not been changed to show that the person was no longer able to weight bear. On the first floor care records were viewed for two people. Again these were a mixture of paper and computer files. The care plan for one person was up to date and reflected the persons needs. Wound management records for the person were good. For the second person most of the records were up to date however there was no continence assessment completed and no personal hygiene care plan in place. The wound care records for this person were good. On the second floor care records were viewed for two people. These included assessments and care plans to show how assessed needs were to be met. Wound care plans and records were satisfactory and provided adequate guidance for staff on how to manage the wound. There was evidence in some of the records seen that residents were involved with preparing them. Residents spoken with were happy with how care was provided. Requirement 1. All residents were registered with a GP and many remained registered with the GP they had prior to admission. Staff said they had good working relationships with the GP and community nursing service. From the care records seen it was evident that staff supported residents to access other healthcare such as optician, dentist, chiropody, dietician and tissue viability advisors. The provider employed a physiotherapist for 2 mornings a week. This person assisted residents with mobility and advised staff on individual resident care and participated in moving & handling assessments. During a tour of the home it was evident residents were provided with pressure relief equipment. Residents spoken with said they could see the GP and other healthcare professionals when needed. Residents and relatives spoken with or who provided feedback were satisfied with how healthcare needs were met. Medicine management was inspected on the first floor and medicines for the residents whose care records were viewed on the ground and second floor were checked. A policy and procedure in relation to medicine management was provided for staff. Each floor had satisfactory storage facilities, a medicine fridge, medicine trolleys to administer medicines and safe storage for controlled medicines. Medicine storage areas were fitted with air conditioning units and daily records were maintained for medicine fridge temperatures. Records were kept for receipt, administration and disposal of medicines. Medicines were mainly supplied in blister packs but some were supplied in individual containers, the pharmacist provided pre-printed administration charts and medicines were supplied on a 4 weekly cycle. A list of staff signatures and a copy of the homely remedy policy was seen on each unit. Management should consider introducing a medicine profile for each resident, should prepare a protocol for administration of ‘as required’ medicines and should ensure that staff who manage medicines are assessed as competent annually. On the ground floor the medicine records and supplies were checked for one person and were found to be correct. A medicine record viewed for a second Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 12 person showed they were prescribed an ‘as required’ medicine however staff had not prepared a protocol for the administration of this medicine. On the first floor medicine storage facilities and recording of medicine records were satisfactory overall. Medicine records were checked for five people. For two people these were correct. For two people there was an error with one medicine, as the amount remaining in stock did not tally with the amount supplied and administered. For the fifth person the risk assessment in relation to self-management of one medicine was inadequate and was not supported by a care plan. On this floor staff had added the resident’s name in large letters to the individual dispensed containers. This was not considered safe practice and should cease. Staff had countersigned hand written entries they made on administration charts. Homely remedy medicine stocks checked were correct and satisfactory arrangements in place to manage and record these medicines. Controlled drug stocks checked were correct. On the second floor medicine records and management for two people were viewed. Medicines were generally well managed and records well maintained. An error was noted in relation to one person’s records. The person had been prescribed a variable dose for one medicine and staff had not recorded the actual dose administered. This made it difficult to complete an audit trail for this medicine. Requirement 2 and recommendation 1. Residents and relatives seen and those who provided written feedback were complimentary about staff and how staff respected resident’s privacy. All bedrooms were for single occupancy and had en-suite facilities, staff were observed knocking on doors before entering rooms, some residents had keys to their rooms and bathroom and toilet doors had locks fitted. All of the residents seen were appropriately dressed in clean well-laundered clothes and a hairdresser visited weekly. Staff were seen supporting residents with personal care and decision making in a calm unrushed manner. Staff were observed moving & handling residents in a polite and inclusive manner. Comments received included “the home is very good”, “staff are kind and caring and make resident’s lives meaningful” and “staff, food and the environment are very good”. One resident was having a manicure from the activity coordinator who was talking to the resident about news events both in and outside the home. Staff responded promptly to the call bells and a resident spoken with confirmed this was usually the case. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had access to a range of suitable activities, were enabled to maintain contact with family and friends and to be involved with decisions about their lifestyle. A varied menu was provided and individual preferences catered for where possible. EVIDENCE: One activity organiser was employed for 30 hours a week to cover the whole home. The manager said that currently discussions were in progress to employ a second person for 15 hours a week mainly to work with the residents on the dementia unit. The introduction of the additional hours would enhance resident’s lives and should be seriously considered. A wide range of activities was provided including quizzes, exercise to music, bingo, card making, church services and arrangements were made for visiting entertainers once or twice each week. Residents spoken with were satisfied with the activities provided and some residents said they did not like joining in organised activities and that staff respected their decision. The activity organiser made efforts to spend one to one time with residents who stayed in their rooms. The home had purchased a larger mini bus and this enabled residents to go out for shopping trips, restaurants, garden centres and to local places of interest. The Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 14 activity person was working with residents to build life scrapbooks. Care records seen included social histories, which were completed with the help of residents and relatives. No social activity care plans were seen in the care records viewed. A disproportionate amount of the activity organiser’s time was spent writing individual entries on care records to show resident involvement in activities. This was discussed with the manager who agreed to review the current method of recording activities. Recommendation 2. The service had an open visiting policy. Relatives seen said they were made feel welcome, were kept informed about their relative’s well being and could have a meal with their relative if they wished. A resident spoken with stated that visitors were able to come at any time. Staff said that visitors were welcome and could use the kitchen areas on the units to prepare refreshments for themselves. Most bedrooms had private phones fitted to enable residents to maintain contact with family and friends. Staff were observed welcoming visitors and offering them drinks. Residents spoken with said staff did ask their opinion and listened to them. For example in relation to what to wear, what time to get up, whether to have a bath, to choose a meal and if they wanted to join in the organised activities. Residents presented as relaxed and comfortable in the home and many commented on the beautiful views they had from bedrooms, the standard of hygiene and the kindness of staff. Staff were observed talking to residents and helping them make personal choices throughout the day. For example staff communicated with residents during moving & handling procedures, at mealtimes and at the start of activity sessions. Meals were prepared and plated up in adequate portions in the main kitchen and brought to the units in heated trolleys. Residents were provided with a choice of two options at mealtimes however it was evident that alternatives were provided if people did not like the options on the menu. A choice of refreshments was provided with lunch and tables were appropriately set including condiments and fresh flowers. Menus were prepared on a four weekly cycle and showed a varied diet was provided. Residents spoken with during lunch said that the meal was nice and others displayed this by eating the meal. Staff offered assistance where needed and residents had access to special crockery and cutlery to enable them to remain independent. Resident’s nutritional needs were assessed using the ‘MUST’ assessment tool, their weight was monitored monthly and advice sought from a dietician as needed. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory systems were in place to safeguard residents and manage complaints. EVIDENCE: A complaints policy and procedure was provided and a copy included in the service user guide and the information pack. Records were kept of complaints made about the service. Since the last inspection the Commission had not received any complaints about the service. Complaint records seen showed that five complaints had been made to the service. These had been investigated and responded to within the timescales in the complaints procedure. Four complaints were upheld and one was not. Residents and relatives spoken with said they knew how to make a complaint and who to talk to if they had a concern. Residents and relatives knew the home manager by name. A policy and procedure was in place relevant to safeguarding adults. The manager was aware of her responsibility to report allegations or concerns of abuse to the local authority and relevant agencies. Staff spoken with displayed a good understanding of safeguarding people and their responsibility to report any concerns to the manager or senior on duty. Training records seen showed that all staff had received training on this topic since the last inspection. Two members of staff spoken with were not aware of the homes ‘whistle blowing’ Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 16 policy. This issue was brought to the attention of the manager. Recommendation 3. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home was well maintained and provided a pleasant and comfortable living space for residents. Residents were satisfied with the environment, the standard of hygiene and particularly with their private space. EVIDENCE: The home was purpose built and opened in 2006. The building was well designed with light airy rooms and lovely views from all bedrooms and lounges. Furnishings and fittings were to a high standard and the premises were clean, tidy and odour free and well maintained. A maintenance technician was employed and ensured minor repairs, health and safety issues and routine safety checks were completed. A gardener was employed to maintain the lovely landscaped gardens. Residents and relatives spoken with were very pleased with the environment and the standard of cleanliness in the home. The home is situated in a semi rule location and all of the residents Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 18 spoken with stated how much they enjoyed being able to look out over the surrounding countryside. Adequate and suitable bathing and toilet facilities were provided and assisted bathrooms had ceiling hoists fitted. Bathrooms, shower rooms and toilets were spacious, clean, well fitted and decorated to a high specification while still looking homely. On the second floor one bathroom ceiling hoist was out of order which meant the bath could not be used. The manager was aware of this issue and it was being addressed therefore a requirement has not been made. Resident’s bedrooms seen were nicely personalised with photos and mementos. Since the last inspection action had been taken to ensure wardrobes in resident’s bedrooms were stable and secure. Residents spoken with said they were very happy with the accommodation provided. File holders were fitted to bedroom walls and these had copies of the service user guide, information packs and the newsletter. Personal clothing was neatly stored and en-suite units were clean and tidy. Resident names were on the bedroom doors. All areas of the home seen were clean, tidy and odour free. Ample supplies of clean linen were seen and resident’s personal clothing was nicely laundered. Sluice facilities were provided on all floors and staff had access to appropriate hand washing facilities and adequate supplies of protective clothing. Sluice areas seen were clean and well organised with a good system in place for storage and disposal of clinical waste. Staff had access to adequate supplies of protective clothing and had washing facilities were appropriately situated with hand cleansing gel provided in corridors. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team had the skills needed to meet the needs of the residents. Satisfactory staffing levels were maintained however management need to review the nursing hours provided on the ground floor. Staff received training relevant to their work and recruitment procedures complied with regulation. EVIDENCE: The staff team comprised of a full time manager, unit managers, registered nurses, care assistants, domestic and ancillary staff. Staffing levels were based on resident dependency and staff rosters seen showed that good staffing numbers were maintained. Copies of the worked rosters were kept and included the names and designation of the staff on duty at all times. On viewing the staff rosters it was noted that the ground floor unit did not have a nurse on duty from 07:30 to 09:00 and from 17:00 to 19:50. During these times a senior care assistant was on duty and any nursing care needed provided by a nurse from the other floors. It was also noted from the rosters seen for the period 29/9/08 to the date of the inspection that there was no nurse on the ground floor unit on three nights. The shift was covered using a senior care assistant and a nurse doing a late shift on another unit administered night medicines. This was not seen as good practice and all efforts must be made to prevent a recurrence. To ensure that all residents had access to a trained nurse at all times consideration should be given to increasing the nursing hours on the ground floor so that a nurse is on duty at Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 20 all times. Staff said that there was a half hour handover period between the senior members of staff at the start of each shift. Residents and relatives spoken with were complimentary about staff and comments made included “staff have residents interests at heart” and “we choose this home because it was superior”. Staff spoken with said the manager was approachable and supportive. Recommendation 4. From information provided in the AQAA and by the manager the home employed 86 care staff. 44 of these had achieved level 2 NVQ or above and 5 people were working towards the qualification. The number of care staff with an NVQ qualification therefore exceeded 50 . Records in relation to recruitment were inspected for two nurses and two carers. A requirement made at the time of the last inspection to have a recent photograph for all employees had been met. Records seen showed that the home’s recruitment procedures were implemented and complied with regulation. There was evidence to show that annual checks were made with the nursing and midwifery council to ensure that all nurses employed were registered. The staff training matrix was inspected and provided evidence of training courses arranged and the names of staff that attended. Some staff training was provided in-house and where needed training was purchased from external trainers. For example some staff had attended dementia-training courses held at Orpington College. Staff spoken with felt they were provided with good training opportunities and two senior carers spoken with had attained NVQ 4 in care and management. From the records seen it was evident that staff received mandatory training such as fire safety, food hygiene, moving & handling and safeguarding adults with more specialist training provided where needed i.e. on the use of syringe drivers, skin and wound care and end of life care. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had a stable management team and some quality assurance systems were in place. Satisfactory procedures were in place to manager resident’s personal allowances. Care staff received formal supervision and systems in place to ensure a safe environment was provided. EVIDENCE: The service was well managed and the manager had the skills, experience and support needed to fulfil her role. The manager was registered with the Commission and achieved NVQ level 4 in management. Staff, residents and relatives spoken with said the manager was approachable and regularly spent time on the units. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 22 Records seen indicated that systems were in place to obtain the views of the residents, relatives and others about the service. Regular meetings were held with staff, residents and relatives and minutes from these were seen. The trust sent satisfaction surveys to residents, their advocates and staff on a regular basis. Staff and residents survey results were seen for August 2008. Both surveys showed satisfaction with the service but neither included an action plan to show how comments made would be addressed. Records were seen for internal audits on key performance indicators for areas such as food, laundry and infection control. There was no evidence to show that internal audits had been completed in relation to medicine management or care planning. Reports were seen for regulation 26 visits. Recommendation 5. A requirement was made at the time of the last inspection regarding the need for staff to receive appropriate supervision. Based on records seen and from talking to care staff it was evident that steps had been taken to provide care staff with regular supervision both in practice and on a one to one basis. However this was not so well organised for trained staff. A system was in place to provide peer group supervision for nurses but not for one to one supervision sessions. The manager agreed to address this. Recommendation 6. Safety records seen were up to date. Records viewed included fire safety, lift service, hoisting and bathing equipment service, gas and electricity. A full time maintenance technician was employed and carried out routine repairs and safety checks. This person also completed routine checks on areas such as hot water temperatures, bedrail fittings, fire safety equipment and wheelchairs. Fire drills were held at time to include all staff and since the last inspection a number of staff had received training on fire safety. Bedrail risk assessments were completed prior to fitting this equipment. Accident records were generally well completed and were reviewed by the manager. Staff should take care when completing forms for accidents that were not witnessed to ensure the information recorded accurately reflects the events. Records seen included the follow up action taken in relation to accidents sustained by residents. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 23 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 4 X 4 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X 4 X X 4 X 4 STAFFING Standard No Score 27 2 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 24 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. 1 Standard OP7 Regulation 15 Requirement Timescale for action 07/12/08 2 OP9 13 Care plans must be prepared to show how all identified needs will be met. Risk assessments must be up to date and reflect the current needs of the person. Accurate records must be kept 07/12/08 for all medicines brought into the home so that an audit trail can be completed. Risk assessments in relation to residents wishing to manage their own medicines must be fully completed and supported by a care plan. The actual dose of a medicine administered must be recorded when a variable dose is prescribed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000067988.V366473.R01.S.doc Version 5.2 Page 25 Coloma Court 1 Standard OP9 2 OP12 3 4 OP18 OP27 5 OP33 6 OP36 A system should be in place to assess the competency of staff to manage medicines annually and evidence kept of this process. A protocol should be developed for the administration of ‘as required’ medicines for residents. A medicine profile should be in place for all residents. The registered person should ensure individual social care plans are prepared with residents. The current system to record activities should be reviewed so that the activity person can spend more time with residents. All staff should be aware of and understand the homes ‘whistle blowing’ policy. To ensure that all residents had access to a trained nurse at all times consideration should be given to increasing the nursing hours on the ground floor so that a nurse is on duty in the unit at all times. The findings of satisfaction surveys should include an action plan to show how issues raised will be addressed to improve the service. Management should undertake regular audits on areas such as medicine management and care planning and where identified implement improvements. Management should ensure trained nursing staff receives formal supervision in line with this standard. Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coloma Court DS0000067988.V366473.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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