Inspection on 13/03/07 for Autumn Cottage

This inspection was carried out on 13th 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Autumn Cottage 160 Ness Road Shoeburyness Essex SS3 9DL Lead Inspector Pauline Marshall Unannounced Inspection 13th March 2007 9:00 Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 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 Autumn Cottage DS0000067941.V324929.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 and 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. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn Cottage Address 160 Ness Road Shoeburyness Essex SS3 9DL 01702 292005 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) Outlook Care Christine Chaplin Care Home 7 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (2) of places Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st Inspection Brief Description of the Service: Autumn Cottage is a purpose built care home that was built in 1993 by the National Health Service. The property is registered for seven people with learning disabilities two of which may be over sixty-five years of age. The home has seven single bedrooms all of which are fitted with overhead tracking. There are two large bathrooms fitted with assisted baths and there are additional toilet facilities. The garden runs along one side of the property and is laid to lawn with a small shed on the patio area. The garden is enclosed with no access from outside the home. In summer months a large marquee is set up in the garden with tables and chairs to enable residents and their visitors to relax outdoors. Autumn Cottage is within walking distance of the seafront and Gunners park; it is close to the local health centre and the West Road shopping centre. There is easy access to all forms of public transport. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. The residents’ weekly contribution ranges from £62.35 to £94.45 and there are additional charges for hairdressing, toiletries and community activities. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for six hours and twentyfive minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff, the manager, deputy managers and the service manager. As part of this inspection surveys were sent to seven residents, seven relatives’ two General Practitioners, eight health and social care professionals and twelve care workers to obtain their views on the service the home provides. At the time of writing this report no residents surveys were returned. Three relatives, two GP’s, one health and social care professional, two care workers and one advocates survey forms were returned and all were positive in their responses. What the service does well: What has improved since the last inspection? What they could do better: Medication administration records should be checked more often to ensure that any medication that is administered is correctly recorded. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 6 The style of documentation used for the care plans should be decided upon and out of date information removed from the current file to ensure that any potential risk to a resident’s health is reduced. Regular residents meetings should be held and the outcomes recorded. The homes induction process should be carried out in line with its own policies. 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. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with sufficient information to make an informed choice and will be fully assessed prior to admission. The home provides each of its residents with a written/pictorial contract. EVIDENCE: The homes Statement of Purpose and Service User Guide are dated May 2006. The Statement of Purpose includes up to date information including photographs of the staff team and a list of the training that they have undertaken. The Service User Guide is in pictorial form. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 9 The last admission to the home was in May 2003 and the local authority carried out the needs assessment. The home has a clear admissions policy and the manager said that any new admissions would be carried out following this policy, using the assessment documentation available from Outlook Care. The assessment documentation addresses health, safety, social, spiritual and cultural needs and includes obtaining details of prospective residents likes and dislikes and their dreams and aspirations. Each resident has a contract with the home that is in written and pictorial form; an unsigned copy was available for inspection, the manager said that the signed copies were at Outlook Care’s head office and that she would obtain a signed copy to keep on residents files. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. The care plan files have all the relevant information in them but contain too much out of date and no longer used records. Regular residents meetings are needed to ensure that they are consulted and participate in, all aspects of life at the home. There is a good risk assessment process in place that encourages and supports residents in taking risks as part of an independent lifestyle. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care files were examined and contained copies of old and new documentation; the manager said that as the home had transferred from the NHS to Outlook Care in October 2006, all existing NHS paperwork is in the process of being replaced with Outlook Care documents. The home has three care folders for each resident; one contains the person centred plan and another the medical documentation, the third contains older paperwork that may need to be accessed. The three care files examined contained all of the relevant information, however the different styles of documentation used at the same time could cause confusion. One of the care files examined had details of the last flu vaccination being administered in 2005; the manager advised that all residents had a flu vaccination in 2006. The document showing the last entry as 2005 was no longer in use but was in the care file with nothing to indicate it was no longer used. Care plans must show how a residents needs are to be met, if the information is not clearly updated to reflect any changes there is a potential risk to their health and welfare. Relative’s surveys included comments on their satisfaction with the care provided, they said the home is warm and friendly and one relative said they had no worries about their child living at Autumn Cottage. Surveys also included comments about how residents were respected as individuals and always encouraged to make their own choices. The manager said that residents meetings are held on a one to one basis with key workers and the named nurse. These had not been carried out as often as planned due to the current staff sickness levels; evidence of one meeting was available for inspection. Regular residents meetings must be held to ensure that they are consulted about how they want to live. All three care files examined contained evidence of risk assessments and plans on how to manage all of the identified risks. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome are is excellent This judgement has been made using available evidence including a visit to this service. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 13 Residents are supported and encouraged to take part in a range of appropriate activities both inside the home and in the local community. The home supports residents to have appropriate relationships and ensures their rights are respected and responsibilities recognised in their daily lives. Residents are offered a choice of meals that are healthy and balanced and mealtimes are flexible and relaxed. EVIDENCE: The homes activities programme includes TV. Videos/DVDs, listening to music, relaxation, cooking, games, puzzles, colouring, hand and foot massage, foot spas, shopping and snoezelum in its own well-equipped sensory room. Professional surveys included comments on how staff continually strives to ensure that residents needs are met including leisure opportunities that meet their individual likes and dislikes. Surveys also included comments on how knowledgeable staff were on meeting residents needs and that the home provides an excellent service. Two residents were going to the theatre on the afternoon of the inspection and one of the residents spoken with said how they were looking forward to the show and that they often went out with staff to the shops and local theatres. The sensory room was in use throughout the day and residents spoken with indicated their enjoyment of the sessions. The home operates an open visiting policy and encourages residents, their friends and relatives to spend time together; in the summer months the home erects a large marquee in the back garden for use by residents and their visitors to picnic together. Staff interaction with residents on the day of the inspection was observed to be kind, caring and respectful. Staff explained their activities at a level and pace that was appropriate for the individual resident. The current resident group at Autumn Cottage are limited in their level of participation of household tasks; however, staff encourages residents to participate as much as they are able. The home operates a four-week rotating menu that offers an alternative choice for every meal. All foodstuffs are purchased locally and shopping is the responsibility of designated care staff. The home ensures that fresh fruit is always available as an alternative snack. Residents spoken with indicated that the food was good and plentiful. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Residents receive their personal support in a way they require and their physical and emotional health needs are met. Medication policy is good and generally medicines are handled well, however on one occasion medication had been administered and not signed for. EVIDENCE: The care files examined contained clear records of resident’s preferences; the person centred plans are being developed and include evidence of resident’s Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 15 participation. Residents spoken with indicated that staff provides their personal care in private and that the home is flexible with its routines. Each resident has his or her own personal aids and equipment that has been provided as a result of a professional assessment of their requirements. Residents health care needs are addressed in their individual care plan and their health is monitored and any problems identified are dealt with immediately. All healthcare visits are undertaken in private. The current resident group at Autumn Cottage are unable to administer their own medication. The home uses a medication administration system and on the day of the inspection the provider company’s service manager undertook a medication audit. The audit identified some gaps on the medication administration sheet (MARS); the tablet count verified that the medication had been given but not signed for. Records of all medicines administered must be accurate to ensure that there is no mishandling. The home has a good medication policy; four trained nurses are employed at Autumn Cottage and they currently administer all medication. The manager said that the provider has requested that all staff receive training to enable them to administer medication and that this training is scheduled to commence over the next few weeks. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Residents feel their views are listened to and acted on and they are protected from abuse, neglect and self-harm. EVIDENCE: The provider has a good complaints policy and procedure that the manager said will be put into practice when a compliment or complaint is received by the home. The homes admission documentation includes details of how to complain should the need arise. The manager said there is a compliment and complaints folder set up in which all compliments and complaints will be recorded. The home has regular visits from an advocacy service and they will assist residents in dealing with any issues. An advocate is currently working together with a resident regarding a complaint about health care services they had received. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 17 All staff has received the Protection of Vulnerable Adults training with the NHS; the manager said that the new provider intends to arrange further training through Southend Council. Staff spoken with had a good knowledge of the homes procedures and knew what to do in the event of suspected abuse. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Residents live in a clean, hygienic, homely, comfortable and safe environment. EVIDENCE: The home is well decorated in light bright colours and all of the rooms are cheerful and airy, the hallway is a little dark during the day if no lighting is Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 19 switched on. The furniture is of a good quality and is well maintained. All of the bedroom floors are fitted with non-slip vinyl flooring and the manager said this is because of the use of wheelchairs and equipment together with the level of incontinence would make it difficult to keep floors clean and hygienic, the under floor heating would also add to this problem. The manager said that risk assessments on the flooring have been produced and that the results are recorded in the care plans. All rooms in the home have doorways of a sufficient width to allow wheelchair users adequate access. The home has a large laundry room with adequate space to keep soiled and clean linen separate. Incontinence waste is disposed of appropriately and the home has a contractor that makes regular collections. There are clear policies on infection control and hand washing notices are displayed around the home. The manager said that infection control training is scheduled for later this year. The home was clean, pleasant and hygienic and relatives commented in their surveys on how clean the home is. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff and are protected by the homes recruitment policies and practice. Staff are well supported and supervised. EVIDENCE: The home employs four qualified learning disability nurses and has three care staff who have completed their NVQ training; a further two care staff are Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 21 registered to commence NVQ training in September. Residents spoken with indicated that staff was approachable and communicated well with them. Observations of staff interaction with residents throughout the inspection confirmed that residents felt comfortable and relaxed with staff. Staff spoken with understood the need for specialist skills to enable them to communicate well with the residents. Health professional’s surveys included comments on how the home has a very stable staff group that know each resident well. The majority of the staff team have been transferred from the NHS to the new provider Outlook Care and have worked at Autumn Cottage for some years. Recruitment files were compiled by NHS staff and do not contain all the relevant information as required by the Care Homes Regulations. The homes most recent employee commenced on the date of the transfer and the recruitment file contains all of the relevant documents. The new employee had evidence of induction having started, however the induction document was not completed for the first and third month and the employee had been in post for five months. Induction should be carried out as stated in the homes policy. The manager said that training needs are identified at supervision and that as training opportunities become available staff attends appropriate courses. Staff files contained evidence of various training course including service specific issues such as epilepsy. Staff spoken with confirmed that training at the home was good. The manager said that supervision is planned monthly but in reality occurs about every six weeks due to sickness and annual leave. There was a staff supervision sheet pinned on the notice board that showed planned dates of supervisions and the dates they had occurred. Staff spoken with said they felt well supported and supervised. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 23 The home is well run and resident’s views are sought through the quality assurance system, in the development of the home. The health Safety and welfare of residents is promoted and protected. EVIDENCE: The Registered manager is a qualified nurse who has worked at the home for more than twelve years and will be commencing her Registered Managers Award in September 2007. Two deputy managers who both have several years experience in working in the learning disability field support the manager. The provider has an established quality assurance system that the home has adopted. Some surveys have been undertaken and the home is in the process of collating the information they have received so far. The manager said that when all the relevant information has been gathered a report will be prepared and made available to all interested parties including the CSCI. Outlook Care as part of the quality assurance system undertakes regular audits of the home. All staff has up to date moving and handling, fire, first aid and food hygiene training. Further training in matters relating to health and safety is planned throughout 2007. All safety certificates were in place and accident records were adequately maintained. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 X 4 X 5 3 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Autumn Cottage Score 3 3 3 X DS0000067941.V324929.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 1st 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 YA20 Regulation 13 (2) Timescale for action The registered person shall make 30/04/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This refers to the medication that was administered but not recorded in the medication administration records. Requirement 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 YA6 Good Practice Recommendations The style of documentation used for the care plans should be decided upon and any out of date information removed from the current file to ensure that any potential risk to a resident’s health and welfare is reduced. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 26 2. YA7 3. YA34 Regular residents meetings should be held and the outcomes recorded to ensure that their views are obtained and that they are supported to make decisions about their lives. The home should ensure that the induction process is carried out in line with its own policies. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. Autumn Cottage DS0000067941.V324929.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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