Inspection on 19/03/07 for Andrew Cohen House

This inspection was carried out on 19th March 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Andrew Cohen House 22/02/06

Andrew Cohen House 19/07/05

Andrew Cohen House 25/01/05

Andrew Cohen House 20/09/04

Andrew Cohen House 27/01/04

Andrew Cohen House 15/09/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Andrew Cohen House 1 Riverbrook Drive Stirchley Birmingham West Midlands B30 2SH Lead Inspector Sean Devine Key Unannounced Inspection 19th & 20th March 2007 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 Andrew Cohen House DS0000024818.V326541.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. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Andrew Cohen House Address 1 Riverbrook Drive Stirchley Birmingham West Midlands B30 2SH 0121 458 5000 0121 458 4999 sgold@bhamjcc.co.uk 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) Birmingham Jewish Community Care Mrs Sheila Gold Care Home 59 Category(ies) of Dementia - over 65 years of age (59), Old age, registration, with number not falling within any other category (59), of places Terminally ill over 65 years of age (59) Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to accommodate 50 service users over 65 yrs of age who are in need of nursing care (including 4 continuing care service users) for reasons of old age, dementia or terminal illness. 9 service users over 65 years of age in need of residential care for reasons of old age. 22nd February 2006 Date of last inspection Brief Description of the Service: Andrew Cohen is a purpose built two-storey home set in its own grounds that was commissioned in 1993 by the Birmingham Jewish Community. The home provides both residential and nursing care for 59 residents for reason of old age, dementia and terminal illness. Accommodation is provided in large single rooms and the majority have en-suite facilities. There are a number of communal rooms, a library, synagogue and snoozlem room for use by residents in the home. The home is well maintained both internally and externally. There is a pleasant garden to the rear with parking to the front of the building. The home has strong links with the local Jewish Community who provide support and there are a number of volunteers involved with social activities in the home. The fees for the service are Residential care £650 per week and Nursing care £745 per week. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was visited unannounced by two regulation inspectors and lasted for two consecutive days. Prior to the visit ten residents returned “have your say about…” surveys to the commission telling us about life in the home. The manager had completed and returned a pre inspection questionnaire telling us about how they run the home. Two relatives and four visiting health and social care professionals returned comments cards to us about their experiences of Andrew Cohen House. The experience of five chosen residents was looked at including, direct observation of the care they receive, talking to them, reading their care records including their medicine, looking in their rooms and for two residents talking to their relatives. The home have had complaints since the last inspection, records are available including how they looked into the concerns and where required what they have done to make things better. What the service does well: The home provides a real sense of community life, as residents and their families are encouraged to make many of their own decisions including an opportunity to continue their Jewish faith and lifestyle. There is a lot of support from the senior managers and directors, nurses, care staff, ancillary staff and also from a social worker and occupational therapist. The healthcare needs of residents are well planned and effectively met, when there have been concerns in respect of health or protection the staff have always made timely decisions about who needs to be involved. The senior managers and the directors are positive about complaints and how it is an important tool for residents and their representatives to raise their concerns and a vehicle to improve the services. The décor and furnishings are maintained to a good standard. The home presents clean and tidy and many residents rooms have had many personal touches. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 6 Staff recruitment, training and the supervision is conducted in the best interests of the residents. Training is flexible and the manager is aware of the needs of the residents and considers this as part of the training programme. The manager has led, directed and developed the team over a period of years. There are excellent channels of communications and the manager spends a great deal of time with the residents. She is supported by the Director who has on most occasions supported her decisions the director also has a good insight into the needs of residents and how good care is to be delivered. The home has a quality manager who has successfully introduced a system of monitoring and reporting, which involves residents and their representatives. Many outcomes from the quality reviews are being used to continuously improve the service. 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. Andrew Cohen House DS0000024818.V326541.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 Andrew Cohen House DS0000024818.V326541.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): 1, 2, 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it has the ability to ensure that residents are only offered a service if they are positive they can meet their needs and aspirations. Many residents are unsure whether or not they have a contract, which may mean they do not know conditions, restrictions or their rights. EVIDENCE: It was the general opinion of residents that they were provided with a lot of information about the home, relatives also confirmed they had been able to visit or had been involved at the home in their past. Comments included “yes I know about the home, my niece was here and I used to visit regularly” and “I didn’t really want to come in, but I was ill and had very little choice”. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 9 The majority of the residents did not know whether they have a contract or not. During the tour of the home including looking in residents’ rooms many of the residents had service users guides and some confirmed they had it explained to them. The Jewish community provides their own social worker who is based at the home, records show that the social worker had assessed many of the needs of the residents prior to their admission. These residents had the pre admission assessments on their files indicating needs and risks. The home does not provide an intermediate care service. Andrew Cohen House DS0000024818.V326541.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): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to effectively meet the health and personal care needs of residents. This is conducted in a safe and routine manner but could be improved by including more personal choices of residents as determined during assessment. EVIDENCE: The residents’ surveys indicated that they usually receive the support they require and that the staff are available when they need them, comments included “there can be a language difficulty”, “I don’t believe I need all the support I’m offered” and “their (referring to staff) very kind, and I’m very grateful for all their help”. Many residents did meet with the inspectors and when asked about health and personal care support were very positive they received it when needed and when they were unwell. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 11 Residents files had good evidence that where personal care or health care was required that a care plan or risk assessment was written to guide and instruct staff. The evidence was based upon good assessments including nutrition, moving and handling, tissue viability (skin care) and falls. These assessments were regularly reviewed. Care plans had been written for treatment such as infections, pressure ulcer care (after consultation with a tissue viability nurse) and other immediate health needs. There was good recording of appointments with the GP, hospitals, chiropody, physiotherapy and occupational therapist. The home has employed a part time occupational therapist that met with the inspectors and advised on her role, her assessments and how this would benefit the holistic care needs of the residents. The inspectors discussed some improvements with the management team, including further development of care plans ensuring personal choices of dress; toilet, sexuality and culture are reflected in the care plans. There was also some discussion about having two types of care plans, those more clinical and those about the individual resident and their choices and preferences in life. Comment cards received from four healthcare professionals who support the residents included comments such as “Andrew Cohen House gives a high standard of care to all residents, all staff are extremely knowledgeable” and “I have been in practice for 13 years and this is probable the best managed home I attend”. The management of residents’ medication was assessed and found to be well managed and reflective of good practices and legal requirements. Records were comprehensive completed including when medicines are received and administered to residents. Stocks of medication for the five residents were found to be accurate. There are some hand written medication administration records that are often written by one nurse and good practice would be that these records are witnessed and countersigned by another nurse. All medicines were safely stored. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has fully demonstrated that it has the ability to meet the daily life and social activity needs of the residents. There are many good outcomes for residents that improves their well being yet more information is needed in care plans to ensure all staff are aware of how to meet these needs and ensure continuity. EVIDENCE: Each resident is in the process of having their skills and abilities fully assessed by an occupational therapist, who writes a report. This is being used to assist with care planning. There are some very good assessments that refer to the daily life choices of residents, their history and biography. It is clear their religious needs, culture, family and interests are considered, yet this was not always apparent in the care plans. This was discussed at some length with managers and the director and the new deputy manager is keen to make improvements. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 13 There is a programme of activities and a dedicated staff team who plan, organise and oversee activities. Each week has a dedicated activity programme. Examples include film afternoon on the large screen, hand therapy, music and social skills therapy, progressive mobility, flower arranging, table activities, cooking, quizzes, shopping trips including City Centre and Touchwood, Jewish history and reminiscence with the Rabbi in the Synagogue and cabaret acts (external entertainers). There was some good evidence in residents records that they do go and take part in many of these activities, most entries describe if it was enjoyable or not. The activity workers maintain their own records and this includes discussion with residents for future planning of activities. The recent Quality Assurance verification report recorded that the entertainments and activities are to a good standard and are greatly appreciated by the service users and their representative. Food standards are extremely good in terms of taste, quality and presentation, with everything being freshly prepared rather than brought in pre-prepared. The menu was seen and reflected the season of the year with lots of hot meals, winter vegetables and cultural requirements of residents. At the time of the visit it was the first day of service for the externally contracted catering staff. The menu detailed choices at all sittings and appeared to have a good nutritional value. Residents who returned the “have your say about…” surveys had mixed views about the standard of meals at the home, five said they usually enjoy meals and five said sometimes comments included. “The meals aren’t what I’m used to”, “we have sandwiches at teatime and the bread is too doughy, otherwise the meals on the whole are okay” and “its hard for me as I used to do a fair amount of cooking and tried many of the old recipes”. At different times of day meals were observed to be an enjoyable social experience for many residents who eat in communal areas such as the dining rooms. However other residents do not enjoy eating in communal areas and prefer to eat in their rooms. There are some gaps in staff training regarding food hygiene, yet this is considered in the new training programme. The residents where needed had specific care plans about their diet, such as a softer options or diabetic meal and for some residents what they were eating and drinking was being closely monitored and recorded by staff. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 14 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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to ensure that the serious concerns of residents and issues relating to their protection are managed quickly and effectively to make resolution and promote the safety of residents. EVIDENCE: All residents who returned the surveys indicated they always know how to make a complaint, a comment included “Usually I speak my mind and after take advice” . The inspectors spent a short period of time “approximately 30 minutes” with a resident who wished to raise some concerns and complaints. These were passed to the manager and director to provide a response and ensure it was managed within the homes Complaints policy. The pre inspection questionnaire recorded that there had been four complaints in the past 12 months and that one had been partially substantiated. It also indicated that there had been one investigation following a referral under POVA. Records at the time of inspection indicate that two more complaints had been received and had been managed following the homes’ Complaints policy. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 15 Staff training records were fully available showing that there are many staff who have not completed training in protecting adults from abuse. The training manager forwarded a schedule with the pre inspection information, which recorded two training events about POVA in January 2007 and at the time of inspection the 2007/08 training programme was discussed as it did not include POVA. The training manager advised that this training will be included and staff will be attending. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 16 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): 19, 20, 21, 22, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that it has the ability to ensure that the environment is always maintained safely, it has the resources to provide a high standard environment yet some close attention to safety issues has been overlooked which may present a risk to residents. EVIDENCE: The residents who returned the survey indicated that the home was always kept fresh and clean one resident commented “even with a mixed crowd”. The pre inspection questionnaire completed by the manager recorded considerable improvements to the environment in the past 12 months; examples of this include new flooring in parts of the home, some new Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 17 equipment in the kitchen, and some new soft furnishings in residents rooms such as curtains. The inspectors had a walk around the home, including communal lounges / dining areas, communal washing facilities and residents’ rooms. There were some areas of improvements needed including ensuring the call system could immediately be activated to emergency if there was a health emergency and also ensuring that all balcony doors in resident’s rooms are kept locked, the doors were checked and locked at the time of the visit. There was more serious concern about a damaged light switch, concerns were discussed with the manager who made immediate arrangements for repairs to be made. Residents’ rooms are large, 51 of the 59 rooms have an en-suite facility and many have balcony’s. There are eight rooms without en-suite where there are communal bathing and toilet facilities. These rooms are allocated for high dependency and have a glass viewing facility, the viewing windows must have a curtain to maintain the privacy of residents. All areas were found to be clean and well equipped including the five bathrooms; six toilets and sluice areas and all had good hand washing facilities. The residents’ rooms seen by the inspectors had many personal additions such as photographs and pictures, televisions and radios; some residents had their own telephone. The bedding, curtains and carpets were fresh and in very good condition. There is ample communal area, including lounges, dining areas and quiet rooms. There were some concerns that one lounge which is used by many residents involved some degree of risk when supporting residents who may need equipment such as hoists and wheelchairs to mobilise. The concern was that space between some armchairs was quite limited. The layout of chairs and tables was discussed primarily with one resident who was happy that chairs were against walls stating this helped with larger group activities and was better as it is easier to see what was happening on the unit. The director and manager advised that they were considering moving some armchairs into another lounge to allow more space for staff to assist residents. There is a synagogue, which is in frequent use. All communal areas are decorated and dressed to a high standard; they are clean, bright and homely. The director advised of the planned extension to increase downstairs floor space (used as a small lounge) to provide a large activity room for residents. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to provide the residents with staff who are available in good numbers, well trained and who have been safely recruited. This may mean that the needs of residents are effectively met and their vulnerability safeguarded. EVIDENCE: The consensus of residents was that staff do listen and act on what they say and that in the main there are staff available when they are needed. Comments included “some do some don’t (listen)”, “full marks, quite pleased and no complaints” and “pretty good on the whole, though some are more willing than others”. The manager provided staffing rotas with the pre inspection questionnaire, this was assessed at the time of the visit and found to be a true reflection of staffing levels. It was evident that at all times there was enough staff on duty in complimentary roles to adequately meet the varying needs of the residents. The training manager furnished a training matrix with the pre inspection questionnaire, and a programme of training for the coming year. It was evident that most staff including nurses, care assistants and ancillary staff Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 19 undertake mandatory training according to their role such as fire evacuation, COSHH, manual handling, food hygiene and infection control. Yet there are gaps and further training to address this has been identified as part of the new training programme. There was good evidence that there is specific training for staff to meet the specific needs of residents’ good examples of this include dementia care, basic kosher and tissue viability. There was also within the programme more training on the specific needs of residents such as understanding diabetes, communications and care planning and yesterday, today and tomorrow. It was a little disappointing that there is no longer planned training for staff this year about the Jewish faith and culture and basic kosher. Since the inspection the homes Director has confirmed that further training for staff has been arranged regarding the Protection of Vulnerable Adults and that during the induction of new staff and through formal tutorials and intermediary courses the Rabbi provides training. The Rabbi also sees staff before all major Jewish festivals where explanations are given and discussion take place. It is recommended that all training is recorded. The pre inspection questionnaire recorded that at present of the 31 care staff 26 have achieved the NVQ 2 in Care or above, which is 84 . The recruitment practices of the home were assessed, it was evident that all required background checks including CRB disclosures and written references are taken up, application forms completed and interviews staged before appointments are made. There was some recent concerns raised which were passed to the manager to look into, this included a member of staff not having a CRB disclosure. The manager provided evidence that the staff member did have a POVA check, with no match check existing and they were awaiting the CRB disclosure. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 20 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): 31, 32, 33, 35, 36, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that the management and administration has its full weight behind providing an excellent care service, it is evident that it is well managed including leadership and direction, communications are very good, it is inclusive and transparent and health and safety is taken seriously. This all goes to provide residents with a home that reflects on how it meets their needs and how it can continue to improve. EVIDENCE: The manager has excellent systems in place to ensure there is good communication in the home. At the time of the inspection she had returned after some time off duty yet she was fully aware of the current and changing Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 21 needs of the residents. She is now supported by the recent appointment of a deputy manager. Over the past 12 months the manager has notified the Commission of any events that have adversely affected the lives of residents and will at times contact the Commission for some advice about regulations. The home has a Quality Assurance (QA) manager who has worked exceptionally well to develop and implement the system whilst at the same time commence the required auditing. The system is externally verified and the recent verification report indicated that the home performs very well when assessed against the standards. The QA manager is keen to work closely with the residents, managers, staff and others to ensure the systems are structured and inclusive and will drive up standards of care. There is good evidence that residents and the relatives are involved in the auditing and the verification report, which includes areas of improvement, is available for all interested people. It is evident due to regular communication with the Commission that the Responsible Individual (Director) frequently visits the home, as yet the Commission have not been furnished with monthly Regulation 26 reports. The home does provide a safekeeping service for residents to deposit small amounts of money and to temporarily store valuables. Records of how this is managed were seen and found to be well maintained, balances matched money and valuables available in the safe. The home will at times purchase items on behalf of residents and receipts are available to confirm expenditure. A central account for some residents to use is available and many safety measures through the risk assessment process are in place. The director is keen not to use the account for any more residents. Records of staff supervision were seen, it was evident that the supervision meetings are conducted frequently and staff performance is being appropriately monitored. Staff are able to develop an action plan with their supervisor covering such areas as performance, roles and responsibilities, ideas for improvements, training needs and other issues. The records about health and safety including maintenance were seen. It was evident that the utilities used in the home being gas, electric and water are regularly tested and serviced. Equipment including fire alarms, emergency lights and equipment is regular tested and serviced. The staff regularly attend fire drills and the fire officer visited the home in April 2006 and left a report with only minor areas of improvements; these have been addressed. The home has a fire risk assessment. Other equipment used in the home such as profile beds, hoists, kitchen and laundry equipment and the passenger lift are also tested and regularly serviced. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 3 X 3 Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 23 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(1)16(2 m,n) Requirement The registered person must ensure that Written care plans are developed to support residents lifestyles identified in assessments. Previous timescale of 30/9/05 not met this requirement is carried forward. The registered person must ensure that all staff receive training about POVA and safeguarding the residents. The registered person must ensure that the eight residents’ rooms with a viewing mirror have appropriate curtains to maintain the residents privacy and dignity. Timescale for action 30/05/07 2. OP18 18(1)(c)(i ) 13(6) 12(4)(a) 30/09/07 3. OP24 30/05/07 Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 24 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 2 Refer to Standard OP9 OP30 Good Practice Recommendations It is recommended that all hand written medication administration records are counter signed by another nurse. It is recommended that all training be recorded. Andrew Cohen House DS0000024818.V326541.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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