CARE HOME ADULTS 18-65
Cashel Cottage 39 Raffin Lane Pewsey Wiltshire SN9 5HJ Lead Inspector
Elaine Barber Unannounced Inspection 8 January 2007 11:30
th Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Cashel Cottage Address 39 Raffin Lane Pewsey Wiltshire SN9 5HJ 01672 563710 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) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Mr Patrick Jones Mrs Jane Abbott Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection Brief Description of the Service: Valued Lives is a private organisation, which operates 5 care homes for adults with learning disability. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by one of the registered persons, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough and Devizes are within 15 minutes’ drive and the larger towns of Salisbury and Swindon are easily accessible. The organisation has a number of vehicles used by the people who live in the homes and they contribute towards the costs. Valued Lives also operates Harlequins, which is a day service used by most people who live in the homes for at least part of each week. They pay a small weekly sum towards this. Cashel Cottage in Raffin Lane, Pewsey, cares for up to four people. The present occupants are all female. All bedrooms are on the first floor. There is one shared bedroom, which was being used as a single at the time of the inspection. The bathroom is also upstairs. There is a small bedroom where staff sleep in. Communal space is on the ground floor. There is a sitting room and dining room, which was being used as a bedroom at the time of the inspection because one person needed a downstairs room. There is also a large garden. The fees range between £817 and £916. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home on 8th January 2007. During the visit information was gathered using: • • • • • Observation Discussion with one of the managers from another home who was present throughout the inspection. Meeting with people who lived in the home Meeting with staff Reading records. Other information and feedback about the home has been received and taken into account as part of this inspection: • • The owner provided information prior to the inspection about the running of the home. Comment cards were received from three relatives. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the inspection visit. What the service does well:
The inspector met all three people who lived in the home. It was not easy to obtain their views directly, especially on brief contact. However, they appeared well cared for and content. The people who lived at Cashel Cottage had been there several years. They had had an assessment of their needs when they moved into the home. Each person’s individual needs were assessed so that their needs could be met. Each person had a written contract with the home and the local authority purchasing their care. Each person had their needs and preferences recorded in a detailed care plan to ensure that their needs were met. The relatives who completed comment cards were satisfied with the overall care provided. People could make choices and decisions in their daily lives. They chose the activities they followed at their day service and at home, the colours of the rooms in their house and where to spend their time. Restrictions were recorded and agreed to ensure people’s safety. They were supported to take risks so that they could remain as independent as they were able. People were provided with a range of activities and opportunities, offering access to their local community. These included holidays, shopping trips, going to the cinema, bowling, the pub and out for meals. People were able to maintain and develop appropriate relationships with family and friends.
Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 6 People were involved in planning the menu, which reflected their choices. People were offered a healthy diet and enjoyed their meals. People had detailed support plans so that they received support in ways they preferred and required. They had access to a range of health care professionals and their physical and emotional health needs were met. Medication was appropriately stored and people had their medication reviewed regularly. People were protected by the home’s policies and practices about medication. There was a complaints procedure and this was in pictorial format so as to be easily understood and people knew how to complain. There was information about the local vulnerable adults procedures and staff had received training about protection of vulnerable adults. This ensured that people were protected from harm. The accommodation was in a house on the outskirts of Pewsey. There was a large lounge and a dining room, which had been turned into a bedroom. There was a separate kitchen. There were two other bedrooms upstairs which were individually decorated and there was also a bathroom with a shower. There were laundry facilities in the kitchen to meet the laundry demands. The home was generally clean and tidy. People lived in a comfortable, clean and safe environment, suitable to their needs. People were supported by suitable numbers of appropriately trained staff. Two members of staff were on duty at all times that people were at home. There was a range of training. One new member of staff had started work in the home since the last inspection. The staff had had all the appropriate checks before starting work so that people were protected by effective recruitment practices. The manager was appropriately qualified to run the home. She was supported by the owner and other senior managers in the organisation so that people were benefiting from a well run home. A quality assurance system had been developed and the views of people who used the service, their relatives and visiting professionals had been obtained. People’s views underpinned all self-monitoring, review and development by the home. People were generally protected by the health and safety measures in the home. What has improved since the last inspection?
There was a requirement at the previous inspection that guidelines must be available for the use of all ‘as required’ medicines, to ensure that they are used within the prescriber’s instructions. This requirement had been addressed and each person who had as required medication had guidelines about the circumstances in which these could be given. This would ensure that the right medication was given at the right time and people were safeguarded.
Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 7 Improvements had been made to the accommodation and to people’s environment. The kitchen ceiling had been replastered, the kitchen cupboard doors and worksurfaces had been replaced. A new boiler had been fitted. 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. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person’s individual needs were assessed so that their needs could be met. Each person had a written contract with the home. However they had not signed their contracts so it was not clear whether they were in agreement with them. EVIDENCE: No new people had moved into the home since the last inspection. All the people had lived there for several years and their needs had been assessed before they moved in. One person was staying in the house from another home run by Valued Lives. They had had an assessment of their needs when they moved into that house. Each of the three people who lived in the home had a contract with the home and the local authority, which purchased their care. These contracts were signed by representatives from the local authority and the home but not by the people or their representative. There was a requirement at the previous
Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 10 inspection that each person must have a contract. One person who did not have a contract had moved out of the home. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. People’s assessed needs were reflected in their individual plans. People made decisions about their lives with assistance as needed. People were supported to take risks and given opportunities for independence. EVIDENCE: Each person who lived in the home had a detailed care plan. The plans included all aspects of personal and health care, safety issues, communication, preferred routines, contact with family, community and leisure activities and spiritual needs. There were also sections on developing independence and social skills. There were weekly review sheets in the personal notes to show that the care plans were reviewed. However the plans were not signed or dated by a member of staff or the person concerned to show when they were
Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 12 developed and by whom. Changes to the plans were not dated. Some information was out of date for example one stated that two people shared a room when one had moved into a room downstairs. One person also had a detailed behavioural support plan agreed with the community nurse. They also had a restraint and safe handling policy, which described the holds which may be used to manage behaviour. The relatives who completed comment cards were satisfied with the overall care provided. Examples of how people exercised choice and decision making were recorded in the care plans and daily records. They chose the activities they followed at their day service. When people returned home at the end of the day they were observed choosing what to do and where to spend their time. People had also chosen the colours for the rooms in their house. Some restrictions were in place, which were agreed with people’s representatives. These included locking the kitchen door at night for safety reasons. Two staff said that this had been mainly because of the behaviour of a person who had left the home. The need for this practice should be reviewed. There was a requirement at the previous inspection that all service users must have individual plans and risk assessments reviewed and updated to reflect current needs and support, which had not been fully addressed. Care plans still needed to be updated. There was a range of risk assessments for each person. There was also written evidence in the personal notes that the people were supported to take risks to promote their independence. A new risk assessment format was being introduced. However, new risk assessments had not yet been completed. The new format included the benefits to people of taking risks. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence gathered during the visit to the home. People were provided with a range of activities and opportunities to go out into their local community. Activities were suited to their individual needs and preferences. People were able to maintain and develop appropriate relationships with family and friends. People’s daily lives had an appropriate balance between necessary routines, and individual choice. People were offered healthy, nutritious and enjoyable meals, in line with individual needs and choices. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 14 EVIDENCE: The people who lived in the home attended the day service run by the organisation on weekdays. Each had a weekly programme showing their choice of activities at the service. They also had a record of community activities in their daily notes and care plans. Staff supported them to access community facilities including the shops, pub, café, garden centre post office and restaurants. They went bowling or to the cinema once a month and to a social club once a fortnight. They went to church on Sundays. At home they enjoyed watching television or videos and walks. They also participated in outings including trips to London and Longleat. Each person had a holiday in the caravan owned by the organisation. The manager who was present during the inspection reported that staff supported the people to maintain contact with their family. They assisted people to make phone calls and visit relatives. Two of the people had regular contact with their family and one person saw their family less frequently. The people also had friends in other houses owned by Valued Lives. The manager reported that people chose the menus by looking at recipe cards. They were also involved in shopping and buying ingredients. Healthy eating was promoted. There was a varied menu. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People received support in ways they preferred and required. People’s physical and emotional health needs were met. People were protected by the home’s policies and practices about medication. EVIDENCE: Each person’s preferred daily routines were recorded in their care plan. These included how they liked staff to support them. Personal care was provided in private. They chose their own clothes and hairstyles. They had specialist support when needed. One person had recently had specialist advice from an occupational therapist about installing a shower. Details about support with health care were recorded in the care plans. Contacts with a range of health care professionals were recorded. These included the GP, dentist, optician, community nurse, psychologist, psychiatrist,
Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 16 occupational therapist and chiropodist. Each person had an annual health check and their health was actively promoted by staff. There was a medication policy and staff received training about medication. Further training was planned in February 2007. Medication was stored in a locked cupboard. Each person’s medication was kept separately in a plastic box and there was a medication record book. There were appropriate records of medication received, administered and returned to the pharmacist. A list of homely remedies had been compiled for each person and agreed by the GP. There was a requirement at the previous inspection that guidelines must be available for the use of all ‘as required’ medicines, to ensure that they are used within the prescriber’s instructions. This requirement had been addressed and each person who had as required medication had guidelines about the circumstances in which these could be given. The ways in which people consented to take their medication were recorded in their care plans. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: There was information available regarding complaints. The procedure was last updated in September 2004. A pictorial version was available within the Service User Guide. Contact details for the CSCI were included. No complaints had been received. The aim was to minimise any likelihood of this, by having strong recording systems that make all staff accountable for the actions of each particular shift period. There was a wide range of information about adult protection issues. This included details about multi-agency procedures within Wiltshire. A ‘Protection’ section in the care plan gave information about the various safeguards in place. These included recruitment checks, staff training, and key individual abilities and relationships that contributed to upholding a person’s welfare. One person who lived in the home had a behaviour management plan and a restraint policy. This had been drawn up by all the staff with the involvement of the community nurse. Physical interventions were described and there were
Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 18 guidelines about which holds may be used and in what circumstances. Staff had received appropriate training in these techniques. Staff assisted people to manage their money and appropriate records were kept. The records for the previous year had been sent to be audited. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lived in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: The home was in a residential area on the outskirts of Pewsey and was in keeping with the other houses in the street. There was a large living room downstairs with soft furnishings, artificial flower arrangements and mobiles which gave it a homely feel. There was also a kitchen and a separate dining room, which had been turned into a bedroom for one person who needed a room downstairs. This room had been arranged as a sitting room during the day for the use of this person. A shower room with toilet had recently been installed for this person and advice had been sought from an occupational therapist about this. Upstairs there was a bathroom, three bedrooms and the staff sleeping in room. The three bedrooms were individually decorated and
Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 20 people had brought their own things into their rooms. People had chosen the colours of their bedroom walls and those of the living room. Improvements were being made to the accommodation. The kitchen ceiling had been replastered, the kitchen cupboard doors and worksurfaces had been replaced. A new boiler had been fitted. There were plans to redecorate all the accommodation. There was a domestic washing machine in the kitchen and the house was clean throughout. However, some of the artificial flower arrangements and two mobiles were very dusty and this detracted from the overall appearance. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. People were protected by the home’s recruitment practices. EVIDENCE: Each home within Valued Lives has some staff specifically allocated to it. Cover is then made up by other staff, who work in more than one setting. The owner’s aim is to employ sufficient people so that, even if they are one staff member down, there are still enough to cover all the organisation’s services without needing to rely on external agencies. Cashel Cottage has four regular staff who cover most of the shifts at the home. There are two people on duty for daytime shifts. They accompany service users when they go out for their planned daily activities. At nights, one person sleeps in. Staff from other homes cover holidays and sickness. An on-call manager is available if required. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 22 There were appropriate recruitment practices and one new staff had started to work in the home since the last inspection. They also worked in one of the other homes and their recruitment records were seen at the inspection there and all required checks had been carried out. Over 50 of staff in the organisation had a National Vocational Qualification (NVQ). Two of the staff had recently started NVQ level two and one had NVQ 2 and 3 in promoting independence. All staff in the organisation had received a range of training including health and safety, food hygiene, first aid, medication, including special methods of administration, and abuse awareness. There were also courses about epilepsy, challenging behaviour, person centred planning, physical intervention, autism, and dementia in people with Down’s Syndrome. This range of training ensured that staff could meet the diverse needs of the people who lived in the organisation. Refresher training was held in November for health and safety, food hygiene, first aid and administration of medicines by special methods. Training about Makaton and updates about protection of vulnerable adults, medication and food hygiene were planned. The owner reported that they also planned to introduce Learning Disability Award Framework training for all staff. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. The registered manager was suitably competent and experienced, and was supported by senior colleagues, so that service users benefited from a well run home. People’s views underpinned all self-monitoring, review and development by the home although the report about these views needs to be published. People’s health, safety and welfare were promoted and protected by the health and safety measures although some attention was needed to carrying out fire alarm checks regularly. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 24 EVIDENCE: The registered person for the organisation was Mrs Jane Abbott. She was also the registered manager for Cashel Cottage. She had lengthy experience of working with people with learning disabilities and had owned and operated her own services for many years. She had a learning disability nursing qualification and was working towards NVQ Level four in management. She was supported by other senior staff within the organisation. Together, they oversaw all five services run by Valued Lives. The other registered managers within the organisation provided support to the various homes if needed. Since the last inspection the registered manager had been working on their quality assurance for the service. The quality assurance framework was based on the systems in the house including policies and procedures, care plans, records and staffing. A consultant had provided advice and guidance about quality assurance. The views of people who used the service, relatives and visiting professionals had been obtained. These had been collated into a quality assurance report for the whole service covering five homes. There was also a draft review report of the previous three years. Areas for improvement were identified and work had started in some areas for example decorating of the homes. The owner reported that they needed to complete the summary of what had taken place over the last three years and type up the goals for the next three years. A copy of this report now needs to be finalised, sent to the Commission and made available to all people who use the service. There was a health and safety policy to comply with the relevant regulations. A number of general risk assessments and safe working procedures had been recorded. There were also individual risk assessments. There were arrangements for the training of staff in moving and handling, fire safety, first aid and food hygiene. A monthly ‘hazard’ inspection of the home was carried out. Hot water temperature regulators had been fitted to the taps. There were Control of Substances Hazardous to Health (COSHH) assessments, equipment was regularly serviced and portable appliances were tested annually. There was a very detailed fire risk assessment covering all areas of the home and records of fire safety checks although two recent fire alarm checks had been missed. Information was available about what to do in the event of a heat wave. Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 2 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 X 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 x Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 26 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 YA6YA9 Regulation 12-1,2,3 15 Requirement All service users must have individual plans and risk assessments reviewed and updated to reflect current needs and support. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care at the care home. The registered person shall supply to the commission a report in respect of any review conducted by him and make a copy of the report available to service users. In order to comply with this requirement the registered person must supply to the Commission a copy of the report about the quality assurance survey and make a copy of the report available to service users. This requirement is outstanding from the previous inspection. Timescale for action 31/03/07 2. YA39 24 (2) 31/03/07 Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 27 3. YA42 23 (4) c v The registered person shall after consultation with the fire authority make adequate arrangements for reviewing fire precautions and testing fire equipment at regular intervals. In order to comply with this requirement the registered person must ensure that the fire alarm system is tested at weekly intervals. 08/01/07 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 YA5 YA6 Good Practice Recommendations It would be good practice for each person or their representative to sign their contract to show that they are in agreement with it and their interests are safeguarded. Care plans should be signed and dated when they are developed. Care plans should be updated as circumstances change. All changes to the care plans should also be signed and dated. The service user or their representative should sign the care plan to show they have been involved in developing their plan. The practice of locking the kitchen at night should be reviewed to ensure that it is for the benefit of people who currently use the service. The appearance of the accommodation could be improved by dusting the mobiles and artificial flower arrangements. 3. 4. YA7 YA24 Cashel Cottage DS0000028392.V292214.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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