Inspection on 20/05/08 for Colebrook Respite Unit

This inspection was carried out on 20th May 2008.

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

Colebrook Respite Unit 11/06/07

Colebrook Respite Unit 31/10/06

Colebrook Respite Unit 14/02/06

Colebrook Respite Unit 31/08/05

Colebrook Respite Unit 07/03/05

Colebrook Respite Unit 09/09/04

Colebrook Respite Unit 19/01/04

Similar services:

Coton Hill House

Doddington Lodge

Far Croft

Churchill House Nursing and Residential Home

Field Farm House

Church Terrace Nursing & Residential Home

Fountain Court

The Forbury

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Colebrook Respite Unit 291 Bosworth Drive Chelmsley Wood Solihull West Midlands B37 5DP Lead Inspector Ashley Fawthrop Unannounced Inspection 20th May 2008 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 Colebrook Respite Unit DS0000004527.V366039.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. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colebrook Respite Unit Address 291 Bosworth Drive Chelmsley Wood Solihull West Midlands B37 5DP 0121 770 6133 0121 770 6144 colebrookdayunit@btconnect.com 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) Family Care Trust (Solihull) Mrs Anne-Marie Yardley Care Home 7 Category(ies) of Dementia - over 65 years of age (7) registration, with number of places Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home can accommodate up to 7 older people who also have dementia, on a respite basis. One person of the 7 accommodated at any one time may be between the ages of 55 and 65 years. 11th June 2007 Date of last inspection Brief Description of the Service: The quality rating for this service is 1 star. This means that people using the service experience adequate quality outcomes. Colebrook Respite Centre is part of the Family Care Trust Organisation. They provide a respite service for people with dementia. Respite is usually offered for up to six weeks a year but can be extended depending on circumstances. Most residents are admitted after a planned admission programme however the centre can after consideration provide emergency placements. People who use the service are aged 65 years and over, although they have the facility to provide for one resident between the ages of 55-65 years at any time. People have to be independently mobile or walk with a walking aid. All accommodation is at ground floor level and accessible by people with disabilities. Two of the bedrooms have en suite facilities. The centre has an assisted bathing and a separate assisted shower facility. There are several communal areas that are shared with the day centre, which is also run from the same premises. One of these is a quiet lounge. People spend time in the day centre during the day if they wish and are assisted by day centre staff. The company has a minibus, which it uses to and from the day centre and for trips. The cost of a week’s stay at the respite unit is between £383.00-£390.00 per week. The lower price has been negotiated for the contracted beds with Solihull Care Trust. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place on Monday 20th 2008. The unit manager came on duty specifically to assist with the inspection. An assistant manager was also on duty along with three care staff, a volunteer and three catering staff. Five people were staying at the respite unit and nine people visiting day care that is located on site. Three people were ‘case tracked’, this involves finding out about the individual’s experience of staying at the unit by meeting with them, talking to them about their experiences, looking at their care files, looking at their environment, discussions with staff on duty and reviewing staff training records to make sure training is provided to meet resident’s needs. Documentation regarding staffing, health and safety, medication and complaints was also reviewed. The inspection process consisted of a review of policies and procedures, discussions with the manager, staff and residents. Other records examined during this inspection included, care records, staff recruitment records, training records, social activity records, staff duty rotas, health and safety and medication records. Notification of incidents received by us from the home and any other information received were also examined. The inspection process enabled the inspector to see residents in their usual surroundings and see the interaction between staff and people using the service. The inspector wishes to thank the manager and her staff for the hospitality on the day of inspection. What the service does well: The atmosphere at the unit was jolly and friendly. People continue to appeared at ease in their surroundings and in the company of staff. A large percentage of the people’s day is spent joining in activities if they wish and chatting amongst each other and with staff. The manager and staff are dedicated to meet the needs of those who they care for and had a great deal of knowledge of individual wants and needs. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 6 Everyone spoken to was positive about the unit and what it achieves. Some of the comments received from residents are detailed below: People said that the staff were kind and helpful and that the home was a lovely place to come and stay. People also said that the they are always made welcome and that the food was good. What has improved since the last inspection? What they could do better: A number of issues remain outstanding from the previous visit. Pre-admission assessments should be used to find out as much information as possible about people before their stay. These should accurately reflect the needs of people on that particular stay. All information in care files should be dated and signed by the person completing the records. If this is not done it is difficult to evidence who completed the information and when. Care plans do not contain sufficient information to guide staff regarding the care needs of residents. To record “full assistance required” does not give Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 7 specific information regarding timings, the type of assistance and how many staff are required to assist. Risk assessments were not up to date and were not linked to a care plan were a high risk was identified. This puts people at risk of having health care needs missed. 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. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 8 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 Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 9 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): 3 and 6 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Pre-admission practices make sure that people are assessed as being suitable to stay at Colebrook Respite Unit. However, not all assessments reflect the needs of people. Limited information is available regarding usual routines at home to enable these routines to continue while in respite care. EVIDENCE: Assessments that were done before people stay at the home was looked at to make sure that before people stay information is collected about them. People stay for a short period of time and then returning to their own home. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 10 While all the people using the service had been assessed some of the information was outdated and did not accurately reflect the needs of the person at that particular stay. The home cares for people with dementia related illnesses and they mental abilities can deteriorate quickly between visits. The unit must make sure that enough information is gathered before each admission to enable staff to meet individual needs whilst maintaining as much independence and usual daily routines as possible. The manager confirmed that a majority of those who stay for respite care already attend the day care facility that is located on site. A pre-admission assessment is undertaken before people attend the day care centre. This information is then used when a person wishes to stay for respite care. Care plans are available for those that attend day care, these are updated and information from these care plans would be used during any respite stay. People visiting the home who are interested in using the service are able to stay for a meal and/or join in activities. Family members can also visit and speak to staff and other service users. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 11 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 and 10 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The recording of people’s health, personal and social care needs do not give staff detailed guidance to enable them to meet the care needs of those that live at Colebrook Respite Unit. People are treated with respect and their rights to privacy and dignity are maintained. EVIDENCE: The care plans of three people in the unit were looked at. Information recorded in care plans was brief and did not have sufficient information to guide staff of the action to take to meet identified health and social care needs of people. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 12 For example one care plan recorded that food intake should be monitored but there was no record that this was done. As recorded at the last inspection one care plan identified an issue regarding sleeping patterns where one person had disturbed sleep and due to inappropriate behaviour could have been disturbing other people there is no further information recorded to say how this should be managed. There was information in the daily reporting regarding the loss of a toothbrush while this was recorded over several days. There was no evidence that the toothbrush had been replaced and gave the impression that the person had not had their teeth cleaned Care files contain a morning and evening report sheet which details any personal care provided. Standardised documentation is ticked when any task has been undertaken, this is timed, dated and signed by the staff member who undertook the task. These sheets record information such as teeth cleaned, feet creamed and details of any District Nurse input. One of the evening report sheets seen did not record that any oral hygiene is being completed. As recorded in the last inspection the manager confirmed that care plans are constantly under review and they are finding it difficult to find a care plan system that is suitable to meet the needs of people who stay for a few days whilst others stay for a few weeks. We recommended that due to the special needs of the people who use the service and the speed in which their needs can increase a new care plan should be commenced at each stay. People are being weighed as a minimum at the beginning and the end of their stays. This is good practice and identifies the weight gain or loss during their respite stay. On one care plan there was evidence of steady weight gain yet there was no evidence that this had been commented on. The manager was aware that this could be because the person is not eating properly at home, if this is the case a risk has been identified and should be acted upon. The senior staff should be auditing the care plans regularly so that they are sure that they meet people’s needs and that where risks have been identified there is evidence that the staff have acted to reduce these. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 13 A member of the management completes an audit of medication to ensure that the medication is correct on a daily basis. The medication administration records (MAR) for the three residents being case tracked were reviewed. People using the service at the beginning of each stay bring in medication. These are counted in and are written on the administration sheet. Each time medication is given and the sheet is signed to say the medication has been given. On discharge the remaining medications are counted and recorded on the administration sheet, this allows staff to calculate that people receive the correct amounts of medication while staying at the unit and mistakes can be identified keeping people safe. Each Medication Administration Record has a photo of the resident to aid staff identification. We were that staff confirm with the persons GP that the medications that have arrived are correct with the correct dose. Staff said that GP usually send confirmation by Fax other times it might be a verbal response. We recommended that where the confirmation is verbal this is recorded by staff and signed and dated as proof that the GP had been contacted. Care staff appeared to have an excellent relationship with respite service users. The atmosphere at the unit was relaxed and friendly. Staff were observed laughing, chatting and joking with service users. Privacy, dignity and respect were maintained throughout the inspection process. People were appropriately dressed and attention had been paid to their personal hygiene needs. People said the staff were warm friendly and helpful. Colebrook is a lovely place you are treated like a five star hotel and staff cannot do enough. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 14 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 and 15 People using the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to undertake regular social and leisure activities and maintain contact with family and friends as they wish. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: Colebrook respite unit continues to care for up to seven people on a respite basis. A day centre is located on the premises and shares some of the same facilities as the respite unit. People are able to join in day centre activities and appear to benefit from the interaction with day centre clients and the activities available. Doors to activity rooms are left open so that people are able to come and go as they please. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 15 Doors to the gardens are also left open and people were seen wandering outside. There are three main activity rooms at the unit, a games room, arts and crafts and a quiet room. DVD players are available for each TV as is free view. A wide variety of activities take place on a daily basis both morning and afternoon. Activities available to people are reminiscence, board games, watching TV, listening to the radio or other music, singing and dancing, arts and crafts, quiet reading all take place regularly. Other games such as dominoes, scrabble, and cards can also be played with small groups of people. Activities take place seven days per week. A hairdresser and chiropodist visit when needed. People using the service have a committee these meetings are used to find out likes and dislikes regarding activities and meals any comments made by people are recorded in the Clients Committee Record Book. There were no minutes of recent meetings available. Daily records in care files record whether a resident has participated in an activity and if not what they have done during the day. Fund raising takes place to raise money for trips. Photographs are on the walls showing activities that people participate in. The managers continues to promote the ethos of the Home which is to maintain and encourage independence ready for the service user’s return to their own Home. Staff were seen promoting and encouraging independence and choice, however care plans contained limited information regarding this. There is an open visiting policy, but visits are not encouraged during lunchtime, as this can be distracting for residents. The kitchen provides meals for people using the respite service, the day centre attendees and other day centres. The kitchen is well equipped to provide the meals. The respite centre has a set menu and people are offered one main meal per day but are able to have alternatives such as salad, omelette, and sandwiches if they do not like the meal available. The chef records any alternatives from the menu that individual’s request. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 16 Menus seen were nutritionally balanced and varied. The kitchen was clean and hygienic and appropriate cleaning, fridge and food temperature records were available and up to date. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 17 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 and 18. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that their concerns will be listened to and acted upon. Systems are in place to protect people from the risk of abuse EVIDENCE: The unit has received one complaint since the last visit. The complaint was acted upon by the home with a satisfactory outcome. The manager must make sure that where there is a suspicion that that a criminal offence has been performed that there adult protection procedures are followed and that the police was informed. There is a complaints procedure and a shortened version in a leaflet to assist those that wish to complain. This comments, suggestions or complaints leaflet “your right to be heard” is given out to people using the service and their families and copies are left in the reception area for people to take as necessary. The leaflet can be available in larger print, as many of the people in the unit or their representatives could have sight impairments. The name and address of the Commission has also been added to the leaflet. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 18 There have been no adult protection issues. All staff have criminal records bureau (CRB) and protection of vulnerable adults (POVA) checks in place before they start work at the unit. Staff continue to undertake protection of vulnerable adults training. The adult protection procedure informs staff that dependent upon the level of seriousness of an allegation, discussions are to be held with Social Services before any decision regarding action to take is made. Social Services have the responsibility to co-ordinate actions regarding allegations of abuse. The respite unit take an inventory of a resident’s possessions on admission, this is important especially in a respite unit where stays can be for short lengths of time. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 19 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, 23 and 26 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment is well maintained providing an attractive, hygienic and homely place to live therefore improving the quality of life for people using the service. EVIDENCE: The centre is purpose built and is well decorated, clean and fresh. Information leaflets and copies of inspection reports are available for inspection in the main reception area. Communal areas were clean and hygienic. People have access to the gardens, which provided a pleasant space for people to enjoy the sunshine. Communal rooms are shared with day centre visitors. A games room, arts and crafts and a quiet room are available. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 20 Since the last inspection the unit has recently been awarded some grant funding and has invested this in the home to improve the quality of people’s lives There is piped music into bathroom this is done to relax people when having a bath as some people find this process stressful. Toilet and bathroom doors have been painted white and have large signs identifying them. This makes it easier for people to find them. New bath hoists and lifting hoists have been purchased. Bedrooms were clean and tidy. People are encouraged to bring items that are important to them when they stay. Some rooms seen had pictures provided by the unit, whilst other residents had bought pictures and ornaments. Two beds that can be lowered have been supplied this makes it easier for people with mobility problems to get in and out of bed. Bedroom floors have a fitted alarm system that can tell when people are up and walking about in the room during the night. Bedroom doors have a picture of the person using the room to assist them to identify their room. Appropriate laundry facilities are available, disposable gloves and aprons were readily available to maintain infection control. Laundry buckets are used to transport soiled items to the laundry. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 21 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 and 30 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The number of care staff with a National Vocational Qualification (NVQ) level 2 will help to make sure that the skill mix of staff on duty will support meeting the needs of residents. Improvements have been made to the amount of induction and ongoing mandatory training undertaken. This make sure staff have the skills to deliver the best care. EVIDENCE: Staff rota’s show that there are sufficient numbers of staff are on duty on a daily basis. During daytime hours Monday – Saturday staff work across the day care and respite unit. Staff allocated to only work in the respite unit work shifts in the evenings and all day Sunday. Three staff files were reviewed to evidence whether the unit follow robust recruitment practices and obtain relevant details before employment of staff. All files contained information including application forms, references, training certificates, criminal records bureau checks, contracts of employment and c.v. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 22 Staff spoken to said that they enjoyed working at the unit and particularly liked the fact that they spent quality time sitting and chatting with residents every day. All of the assistant managers continue to have either a National Vocational Qualification at level three or four. All apart from two staff have obtained or are currently undertaking their National Vocation Qualification at level two. This amount of trained staff has improved since the last inspection and goes some way to make sure that staff employed have the necessary skills to meet the needs of those under their care. All staff undertake the organisation’s induction training which is in line with “Skills for Care guidelines” plus training regarding the Code of Conduct for Social Care Workers. Copies of individual training certificates were held on staff files and a training matrix for the respite unit has been developed. The matrix details the date the training was undertaken, how long the course is valid for and the date of the next training. Records show that training has been offered on a regular basis, mandatory training such as moving and handling, fire safety, basic food hygiene up to date protecting people living at the unit and staff from injury. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 23 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 and 38 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Home has an experienced manager who has an in depth knowledge of the needs of those under her care. However, she is not working at the home full time this has reduced the quality of the management. Systems need to be put in place to ensure that the quality of the service provided meets the needs and expectations of the Service users who live at the Home. Not all health and safety issues have been addressed to ensure that residents live in a safe environment. This could put residents at risk. EVIDENCE: Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 24 The registered manager of the respite unit has achieved a National Vocational Qualification at level four in care and has achieved the Registered Managers Award. In addition has a Diploma in welfare studies. The manager has had long experience as an auxiliary nurse and a support worker. The manager has had training both with the organisation and externally in the care of people with dementia. She is not working all her hours in the unit as she is also covering another role, this means that people are not getting the full benefit of her experience and ethos of the unit. Quality assurance documentation have been produced and will be available for use shortly. Questionnaires have been developed but not sent out. These are forward to the people using the respite service when they have left the placement. The manager discussed some audits that take place, for example a six monthly internal audit covering aspects of finances, staffing and environment takes place. Social services also undertake an annual contract audit. The people’s committee continues to meet and issues are acted upon this is a form of quality assurance and is evidence that the unit is run in the best interests of people using it. The unit was having visits from a representative of the registered provider. The respite unit tends not to keep money for residents as they are on short stay. No funds were being kept on behalf of residents at the time of the visit. The manager confirmed that residents do not usually bring any money with them when only staying for a very short period of time. A discussion was held regarding staff supervision. The manager confirmed that supervision has improved all staff receive four sessions a year plus an annual appraisal. The assistant managers supervise care staff and the manager supervises the assistant managers. Legionella test and hot and cold-water temperature records were reviewed and found to be in good order. Weekly fire alarm were up to date, the environment risk assessment was last done in May 2007 and is due for updating. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 25 Maintenance records for the gas supply, hoists and fire system were all up to date. Training records did demonstrate that staff have undertaken fire training recently. Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 26 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 X 3 X 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 2 3 X N/A 3 X 3 Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 27 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 12(2&3) Requirement Care plans must reflect the current needs of people and clearly inform the care staff on care to be given or action to be taken regarding all aspects of health and personal care. All risks identified must have actions in the care plan to minimise them. (Outstanding since 31/10/06) 3 OP16 15 The registered person must make sure that when investigating complaints that the procedures relating to vulnerable adults must be followed 31/07/08 Timescale for action 31/07/08 2. OP7 13(1) 31/07/08 Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 28 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 OP3 Good Practice Recommendations Pre-admission assessments should reflect the needs of people when they come to stay at the unit. Staff should audit care plans on a regular basis to make sure staff are acting on information appropriately Where confirmation is obtained from GP’s regarding the accuracy of people’s medications on admission is verbal. This should recorded and dated appropriately. 2 3 OP8 OP9 Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Colebrook Respite Unit DS0000004527.V366039.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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