Inspection on 21/12/05 for 14 Cook Close

This inspection was carried out on 21st December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

14 Cook Close 07/11/06

14 Cook Close 30/06/05

14 Cook Close 04/10/04

14 Cook Close 24/03/04

14 Cook Close 19/11/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 14 Cook Close Dovercourt Harwich Essex CO12 3UE Lead Inspector Neal Cranmer Unannounced Inspection 21st December 2005 09:30 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 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 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 14 Cook Close Address Dovercourt Harwich Essex CO12 3UE 01255 240095 01255 240095 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) The Brain Injury Rehabilitation Trust Mrs Suzette Anne Doherty Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 3 persons) 30th June 2005 Date of last inspection Brief Description of the Service: Cook Close is a detached bungalow situated in a residential area of Dovercourt. The home has three single bedrooms. The home caters for the needs of three gentlemen who have cognitive, behavioural and functional deficits resulting from acquired brain injuries. The registered provider is The Brain Injury Rehabilitation Trust, a charitable organisation which operates registered homes nationally. The sister home to Cook Close is Myland House in Colchester, which is approximately 20 miles away. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over one day in December 2005. Seventeen of the forty-three standards were inspected; of these thirteen were met, with four being minor shortfalls. During the course of the inspection all three service users residing at the home were spoken to, as was the registered manager and two staff members. In addition, a range of documentary evidence was sampled. On the day of the inspection the home was found to be clean and tidy with no evidence of any foul or unpleasant odours. What the service does well: What has improved since the last inspection? What they could do better: The home needs to continue to ensure that all staff treat service users with the dignity that they deserve, and to ensure that staff respect service users’ privacy at all times. The home needs to ensure that records pertaining to staff recruitment are maintained in accordance with the requirements of Regulation 19, Schedule 2 of the Care Homes Regulations. The home needs to further develop its processes for ensuring that service users’ views are sought in respect of menu planning at the home. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 6 The care planning processes at the home require further development for them to comply with regulatory requirements. 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. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the outcomes for this set of standards were inspected on this occasion. EVIDENCE: 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Care plans continue to require some further development to meet with regulatory requirements. Service users are supported to make decisions about their daily lives which are only ever contravened when identified in the assessment of need. Service users are supported to take risks as part of developing and maintaining their independence. EVIDENCE: The care plan sampled indicated that identified needs were well documented, clearly and concisely. Although the goals were quite basic, dates for review were seen to be set. The care plan identified a routine to be followed for supporting the service user. The daily narratives seen did not bear any resemblance to the identified care objectives. Records indicated that service users are supported to make choices about their lives and this was only limited when the assessment of need clearly identified the need. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 10 Risk assessments clearly identified the nature of the risk and precautions, with review dates seen to be set. The risk assessments seen were generally quite basic, but provided clear and concise information. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17. The home needs to undertake further work with staff to ensure they are all working in a way which ensures that service users’ right to privacy are respected at all times. Some dispute exists regarding service users’ involvement in the development of the home’s menus. This needs to be resolved to ensure that service users are actively involved in the preparation of menus with the home being able to evidence it. EVIDENCE: At the previous inspection a concern was expressed by a service user with regard to their privacy, i.e. staff entering their room without knocking. The service user on this occasion spoke of things having improved, although there still continued to be odd occasions when staff entered without knocking. Service users were seen to have unrestricted access to all areas of the home and its grounds. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 12 Staff were witnessed interacting well with service users. Evidence was seen of jovial banter taking place between service users which was clearly being invited by the service users themselves and was at all times reasonable and acceptable. The home’s menu was sampled for the week commencing 19th December 2005 and was seen to be seen varied and nutritious. It indicated that meals were being provided three times a day, at least one of which was seen to be cooked. However, discussion with service users indicated that they are still not consulted on the development of the menu. This point was disputed during discussion with staff who spoke of discussing the content of menus with service users at the beginning of each week. The food stocks sampled on the day of the inspection were seen to be adequate. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20. Service users’ health care needs are well meet with records pertaining to these being well documented. The home’s medication procedure was sampled and was deemed to be in order. EVIDENCE: All service users are registered with a General Practitioner. Records are kept of all healthcare interventions and evidence was seen of all service users having received flu vaccines. All service users receive input from the organisation’s clinical psychology and psychiatry professionals. The home’s medication administration process was sampled and records seen were in order. All staff administering medication have received training from the local pharmacy. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home’s Complaint and Adult Protection Procedures are robust in terms of protecting service users, and evidence would suggest that service users’ views are listened and responded to accordingly. EVIDENCE: The home has a Complaints Procedure that is corporately developed, which contained reference to the Commission for Social Care Inspection. Since the previous inspection the home has received one complaint which was investigated appropriately. The home’s Adult Protection Policy is also corporately developed, although the home follows the Essex County Council’s Guidelines for the reporting of allegations of abuse. The registered manager stated that all staff have received training in this area. During the course of the inspection a service user spoke of a concern relating to a member of staff who had been working at the home. The service user stated that the registered manager had responded to this issue as a matter of urgency and the staff member was no longer working at the home. During discussion with the registered manager about the allegation it was suggested that the manager provide a retrospective Regulation 37 report to the Commission and consult with the local Social Services Department as to whether a Protection of Vulnerable Adults referral should be made. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 28. Service users are provided support in an environment that is homely and comfortable. Service users’ bedrooms were seen to be equipped to enable service users to maximise their independence. Toilet and bathing facilities at the home were adequate to meet the needs of the service users. Shared space at the home was adequate to meet the needs of the service users. EVIDENCE: The home is fit for its stated purpose being in keeping with the local community. The premises are accessible to all service users, providing good level access. Furnishings and fittings were seen to be of a good quality and were domestic in nature. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 16 Service users’ bedrooms viewed were reasonably well equipped with bedding and floor coverings being of a type suitable to the needs of the service users. Power sockets were at a premium, although the registered manager stated that capital funding had been agreed to install more sockets. The home is equipped with adequate toilet and bathing facilities to meet the needs of the service users and these are positioned in close proximity to bedrooms, dining rooms and other communal areas. Outdoor space provided at the home is proportionate to the number of service users and staff on duty. Kitchen and laundry facilities were domestic in nature. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36. The home’s recruitment process continues to require further development in order to comply with regulatory requirements. Service users are supported by a team of staff who are well trained. Service users are supported by a team of staff who are appropriately supervised. EVIDENCE: Access to staff records was not possible due to the home manager being away. It was stressed to the registered manager that they must have access to staff records in the absence of the home manager. The previous requirement from the last inspection has, therefore, been carried forward. Each member of staff has a training record maintained. Training needs are identified during supervision and certificates of training undertaken since the previous inspection were available for viewing. Training is provided by a dedicated training co-ordinator from one of the organisation’s other homes. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 18 Records sampled evidenced that formal supervision is being provided every six to eight weeks and a record is maintained of supervisions having been undertaken. The home manager has received training in providing supervision. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39. The home has a process for collecting and collating the views of service users and others. EVIDENCE: The home has a corporately developed policy on quality management. Representatives of the Disabilities Trust carry out annual quality audits which include the views of service users living at the home. In addition, monthly Regulation 26 reports are provided to the Commission. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 3 28 3 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x x x 3 x x x x 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA16 Regulation 12 (4a) Requirement Timescale for action 28/02/06 2. YA34 19, Schedule 2 3. YA6 15 The registered person must ensure that the care home is conducted in a manner that respects the privacy and dignity of service users. This relates specifically to staff entering service users’ rooms without their permission. The previous timescale set of 01/08/05 was not met. The registered person must 28/02/06 ensure that staff recruitment records are maintained as per Schedule 2 of the Care Homes Regulations. The previous timescale of end of November 2004 not met Records were unavailable for inspection due to them being locked away and inaccessible. Therefore this requirement has been carried forward. The registered person must 28/02/06 ensure that service users’ care plans are kept under review and that records relating to the care plans are consistent and relative. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 22 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 YA17 Good Practice Recommendations I t is recommended that the home finds a way to ensure that service users feel they have been consulted in relation to menu planning and that their views and wishes have been taken into account. 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 14 Cook Close DS0000017722.V262305.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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