Inspection on 30/06/05 for 14 Cook Close

This inspection was carried out on 30th June 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 21/12/05

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 Announced 30 June 2005 th 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 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 Stationary 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 I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 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 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 (CRH) 3 Category(ies) of Learning disability (LD) registration, with number of places 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 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) Date of last inspection 4th October 2004 Brief Description of the Service: Cook Close is a detached bungalow in a residential area of Dovercourt. The home has three single bedrooms. The registered provider is The Brain Injury Rehabilitation Trust, which is a charitable organisation. The organisation operates registered homes nationally. The sister home to Cook Close is Myland House in Colchester, which is approximatelt 20 miles away The home caters for the needs of three gentlemen who have cognitive, behavioural and funtional deficits resulting from aquired brain injuries.. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which was carried out over one day in June. Twenty-six of the forty-three standards were inspected; of these twenty-two were met, with the remainder being partially met. During the course of the inspection the views of all three-service users residing at the home were sought, and have been used to inform much of the detail of this report. One staff member was spoken to, and 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 offensive odours. What the service does well: What has improved since the last inspection? One service user spoken with spoke of a significant improvement in access to community based activities. Some internal repairs to the home have been carried out. Since the last inspection in October 2004 a registered manager has been appointed to the home. The manager in question also has responsibility for Cook Closes sister home Myland House in Colchester, although day to day operational responsibility for Cook Close is co-ordinated by a designated house manager. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 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 standard(s) No standards were inspected from this section on this occassion. . EVIDENCE: 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 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 standard(s) 10. Evidence seen suggested that service users confidentiality is respected. EVIDENCE: The home’s policy on confidentiality clearly laid out the procedures to be followed in relation to protecting service users’ confidentiality. Files pertaining to service users were seen to be stored safely and securely. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12,13,14,15,16 and 17. Service users spoke of being supported by the home to access the community. Service users spoke of being supported to maintain links with families and friends. The menus seen were varied and nutritious, although discussion with service users presented another view. EVIDENCE: None of the service users have any paid or voluntary employment. One service user attends the local college for a course on information technology, although this has currently come to an end for the summer. It is currently under review with the service user as to whether they will wish to continue after the summer break. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 11 One service user spoken with during the course of the inspection, who prior to acquiring their injury had a naval interest, spoke of continuing their interest in going sailing periodically and maintaining their contact at Royal Navy Association meetings. Discussion with the service users and the home leader indicated access to a range of community based activities e.g. • • • • • • • • Attending gym Maintaining contact with Royal Navy Meetings PHAB Club Attending college Visits to restaurants Trips out to the pub Shopping Visits to the local parks. All three service users were supported to vote in the recent General Election via postal votes, although two chose not to. Service users continue to be supported to pursue individual interests and hobbies. Discussion with service users indicated that the home’s policy on the receiving of visitors is one of an open door approach; they spoke of being free to choose where they received their visitors. Service users indicated that generally speaking staff do not enter their rooms with out permission, although some are apt to. Two service users spoke of staff opening their mail on their behalf, but only with their expressed permission. However, one service user spoke of his mail being scrutinised first. Discussion with the home leader clarified the rationale for this action, which although the service user was aware of, did not agree with. However, it was recognised that this is related to a protection issue for the service user, and was subsequently recorded as an infringement of right issue. Discussion with the service users indicated that they felt they were not involved in the menu planning. Further exploration of this point clarified that they are but, as they themselves expressed, unless the menu was made up entirely of chips with everything they would probably not be happy. They spoke of the meals being very healthy, e.g. salads with everything, although they spoke of the quantity being good. Service users spoke of receiving three meals a day, at least one of which was cooked. The home maintains a record of food consumed; the menus seen were varied and nutritious. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19. Service users healthcare needs were well met and catered for. EVIDENCE: Service users are all registered with a local General Practitioner. Records pertaining to service users’ healthcare needs were seen to be adequately maintained. On the day of the inspection a review was witnessed being held at the home, called as the result in a change in the health of one of the service users. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 22 and 23. The home;s comlaints and protection procedures were deemed to be robust for the protection of service users. EVIDENCE: The home has a robust complaints procedure, which was deemed to comply with regulatory requirements. The home’s Adult Protection and Whistle Blowing Policies were both in order. The home leader confirmed that all staff had received training on the protection of vulnerable adults. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 24,25,26,27,28,29 and 30. The environmental standards at the home are generally good. EVIDENCE: A tour of the premises found the home to be in a generally good state of repair. Some minor areas of work were identified by the home, but had already been identified to head office and confirmation for work to begin was awaited. The home’s premises were seen to be safe and accessible to all service users, and met the needs of the service users in a comfortable and homely way. All three service users’ bedrooms were viewed and seen to meet their individual needs and lifestyles. Rooms were seen to be appropriately equipped and there was evidence of service users’ personal possessions. Toilet and bathing facilities at the home were adequate to meet the needs of the service users. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 15 Shared space within the home is adequate to meet the needs of the service users. In addition, the home has good outside communal space. The home’s kitchen and laundry facilities were domestic in nature. The home has a range of aids/adaptations available to help service users to maximise their independence, e.g. • • • • • • Wheelchair accessible shower room Bath chair aid Toilet hand rail Hoist Standing frame Zimmer frame. The home’s laundry facility is domestic in nature; hand washing facilities were seen to be available; floor surfaces were impermeable; and walls appeared to be easily cleanable. On the day of the inspection the home was seen to be clean and tidy and free from any offensive odours. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34 and 36 Staff have job descriptions. Staff were felt to be supported by a competent and effective team. The homes recruitment processes continue to require further development. Staff receive formal supervision. EVIDENCE: Discussion with staff evidenced that they have job descriptions which they felt were reflective of their roles. Staff spoken with were aware of the General Social Care Council’s Code Of Conduct for Social Care Workers. Observation of interactions between staff and service users indicated that staff are accessible and approachable. Staff spoke of having received training specific to the needs of people with an acquired brain injury. The home continues not to employ staff under the age of 18; it has recently reviewed its staffing levels due to the change in need of one of the service users. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 17 The home’s recruitment processes continue to require some further development to comply with regulatory requirements. Discussion with staff and the home leader indicated that staff receive formal supervision every six weekly. Staff spoke of having access to the home’s policies and procedures. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,42 and 43. The manager provides sound leadership and management. The homes quality monitoring process continues to require further development. The home promotes safe working practices which safeguard the health and welfare of the service users. The homes business plan would benefit from further development. EVIDENCE: Staff spoken with spoke of the management team being open and approachable. It was indicated that the management team provided a sense of direction and leadership. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 19 Although the home has disseminated quality assurance questionnaires, these are returned to the head office. There is, therefore, no process by which the home is able to analyse the returned information and use it to improve the quality of its service provision. The following safety certificates were viewed and seen to comply: • • • • Electrical installation certificate Gas safety certificate Fire extinguisher safety certificate Vehicle tail lift inspection report. The home has a basic business plan. It was suggested that consultation be sought around further developing the business plan. The home’s certificate of public liability was seen to be current. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 14 Cook Close Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 3 3 I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 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 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 registered person must ensure that staff recruitment recordS are maintained as per schedule 2 of the Care Homes Regulations. (Previous timescale of end of November 2004 not met) The registered person must develop a quality assurance system within the home. (Previous timescale of the end of November 2004 not met) Timescale for action August 2005 2. YA34 19, Schedule2 . October 2005 3. YA39 24. October 2005 4. . 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 Standard Good Practice Recommendations I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 22 14 Cook Close 1. YA 17 I t is recommended that the home find a way to ensure that service users feel that they have been consulted on in relation to menu planning, and that their views and wishes have been taken into account. 14 Cook Close I56-I05 S17722 14 Cook Close V226589 AI 300605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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. 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