Inspection on 07/02/07 for Combs Court Residential Home

This inspection was carried out on 7th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Combs Court Residential Home 07/11/07

Combs Court Residential Home 07/06/06

Combs Court Residential Home 13/09/05

Combs Court Residential Home 04/04/05

Combs Court Residential Home 12/10/04

Combs Court Residential Home 27/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Combs Court Residential Home Edgecomb Road Stowmarket Suffolk IP14 2DN Lead Inspector Jane Higham Unannounced Inspection 7th February 2007 09.25 Combs Court Residential Home DS0000024362.V329824.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 Combs Court Residential Home DS0000024362.V329824.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 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. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Combs Court Residential Home Address Edgecomb Road Stowmarket Suffolk IP14 2DN 01449 673006 01449 674203 combcourt@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Limited 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) Post Vacant Care Home 30 Category(ies) of Learning disability (30), Learning disability over registration, with number 65 years of age (11) of places Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6th December 2006 Brief Description of the Service: Combs Court is a care home providing personal care and accommodation to 30 adults with a learning disability, eleven of whom can be over the age of 65. It is owned by Parkcare Homes Ltd and is a member of the Craegmoor Group Ltd. Combs Court is situated in the small village of Combs Ford. It is close to the village centre and within walking distance of several shops and a bus link to Ipswich & Bury St Edmunds. The establishment comprises of two eight bedded bungalows, one eight bedded house and one double and four single flats for more independent people. There is also an office block, which incorporates a resident day care centre. Combs Court is accessed by a short drive and there is parking beyond for visitors and the homes transport. Combs Court Residential Home DS0000024362.V329824.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 of Combs Court, a thirty-bedded residential home for adults with learning disabilities, situated in the village of Combs Ford. The inspection was carried out on 07 February 2007 over a period of seven hours. The home is owned and administered by Parkcare Homes (No.2) Limited which forms part of the Craegmoor Healthcare group. The key inspection focused on the care standards relating to Care Homes for Adults. The report has been written using accumulated evidence gathered prior to and during the inspection. The National Minimum Standards and Care Homes Regulations 2001 are referred to throughout this report and any non compliance identified. All key standards were assessed as part of the inspection. The previous key inspection took place on 07 June 2006, followed by two random inspections carried out on 25 September 2006 and 06 December 2006 respectively. The Manager of the home was present for the duration of the inspection and the Inspector had the opportunity to talk to both residents and staff members. At the time of the inspection the home had three vacancies, two within the supported flats and one in Bungalow 2. What the service does well: The home ensures that prospective service users receive an individual assessment of need which confirms that the identified needs can be met by the service. They also ensure that residents placed at the home are in receipt of a contract. Residents are accommodated in a homely environment, in “family” groups and are provided with opportunities to join in both leisure and educational activities. The home ensures that it meets the general health care needs of service users and supports them to access community healthcare resources. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is of concern to the Commission that the current manager has been in post for eleven months and as yet has not submitted an application for registration, despite a requirement being made at each of the three previous inspections. The service provider, must without delay ensure that an application for registration is received by the Commission. Whilst some improvements have been made to the environment over the last nine months there have been continued delays to the replacement of carpets and vinyl flooring in Bungalow 2 and at the time of this most recent inspection, these shortfalls remain unaddressed. Whilst the home has an overall training plan for care staff, some newly recruited staff are being permitted to work alongside residents without first receiving training in mandatory areas such as moving and handling and health and safety. Care plans are unwieldy, disorganised and are not user friendly and it is therefore difficult to access relevant information quickly. It was of concern to the Commission that at the time of the inspection, one resident, who had been living at the home for over three months had not been provided with a care plan which was relevant to their life at the home and staff were still referring to a care plan produced in a previous care setting. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 7 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. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 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 Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can expect to receive an individual assessment of need prior to any permanent placement taking place. Prospective residents can also expect to have the opportunity to visit the service before making any decision about whether they would wish to live at the home. When moving into the home, service users can expect to be issued with a placement contract and a copy of the associated terms and conditions. EVIDENCE: For the purposes of the inspection, the Inspector examined the pre-admission information gained prior to the two most recently admitted residents coming to live at the home. One resident had moved into the home three months prior to the inspection and the other had been living at the home for approximately two years. The home was able to evidence that in both cases an assessment of need had been carried out prior to either resident moving into the home. One of the residents had come to live at the home from a different part of the country and the home was able to evidence that the service users had visited the home along with their parents and the manager had carried out a preadmission assessment at that time. The home was also able to evidence that Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 10 in the case of the other resident, selected for the purposes of case tracking, a comprehensive pre-admission assessment had been carried out by the placing authority. The home was able to evidence that in the case of both residents a contract and terms and conditions document had been issued. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Residents living at the home could not necessarily expect to be provided with an individual plan of care which detailed how their assessed individual needs were to be met and the levels of support required. Residents could, however, expect that where a care plan existed, their preferences, likes, dislikes and choices were documented. Not all residents could expect to be supported to take risks on the basis of an individualised risk assessment around their daily lives. EVIDENCE: As part of the inspection process, the Inspector examined the care plans of the two most recently admitted residents. In the case of the service user who had been resident at the home for approximately three months, whilst a care plan was in place this had been produced whilst living at a previous care setting and was not relevant to their daily life within Combs Court. No care plan had been Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 12 produced which identified the service users assessed needs and the level of support required to ensure that those needs were met. In the case of the second resident selected for the purposes of care tracking, an individual care plan was in place which detailed the levels of support required in relation to areas of daily living including, communication, personal care and psychological and physical well being. In addition to outlining the assessed needs and interventions, the care plan provided details on the resident’s preferences in relation to personal care and activities of daily living. In general both care plan folders needed to be more streamlined as they contained too much out of date information and did not immediately inform the reader of the current needs and level of support required by the individual. Whilst risk assessments were in place for both residents selected for the purposes of case tracking, in the case of one resident these had been produced in a previous care setting and were not relevant to risks involved in their daily life at Combs Court. Relevant risk assessments were in place for the other resident and covered identified areas of risk including personal injury. Whilst a review sheet was attached to each risk assessment, these had not been completed and therefore there was no evidence to show that these documents were current or had been reviewed regularly. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living at the home can expect to be offered opportunities for education and work experience. They can also expect that where desired they can take part in a range of leisure activities which are appropriate to their needs and abilities. Service users will be provided with a menu of meals which are both varied and nutritious. EVIDENCE: The home was able to evidence as part of the inspection, that it supports residents to access both education and work opportunities. At the time of the inspection, one resident was undertaking a work experience programme for four days a week at Otley College and another resident had just enrolled on a literacy course with Learn Direct. On the day of the inspection a group of residents were enjoying a pottery session lead by an ASDAN worker as part of a creative skills course. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 14 The home has its own day centre which offers a day service to the majority of service users. The day service offers a wide range of activities, several of which involve the use of local community resources. Activities on offer were displayed on a plan, in a user friendly format, sited outside the day centre. These included the use of local pubs, a snooker hall, cinema, bowling alley and swimming pool. A mobile library visits the home on a regular basis. On the day of the inspection several residents had been attending a local learning disability resource centre. The home was able to evidence that if offers residents a range of leisure activities as indicated above. The home has its own transport which is used to take service users to various activities, although some are able to use public transport. The day service also runs a lunch club once a week to ensure that residents who wish can mix socially with one another. Some of the older residents also access a lunch club within the community. The home has an open visiting policy and residents are supported to visit relatives at the family home. One resident was reported to be spending every weekend with their relatives. The home was able to evidence through inspection that residents have unrestricted access throughout the home and grounds and there are no locked exists or entrances. All residents are provided with single room accommodation, although residents accommodated in the supported flats have their own living, kitchen, bathroom and bedroom accommodation. All single bedrooms seen at the time of the inspection were fitted with appropriate privacy locks. The previous inspection had noted that a privacy lock was missing from the shower room door, in Bungalow 2, but this had since been addressed. There is no centralised kitchen on the site and resident meals are prepared in the domestic style kitchens sited on each unit. Residents living in the supported flats are enabled to prepare their own meals or may join other residents in the bungalows or house. The home was able to evidence that each house has a planned, varied and nutritious menu of meals which caters for individual tastes and preferences. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living at the home can expect to have their personal preferences taken into account and that the home is flexible in relation to the preferred daily routines of individuals. Service Users are protected by the home’s policies and procedures in relation to the safe storage and administration of medication EVIDENCE: The care plan of one of the two service users selected for the purposes of case tracking evidenced that preferences in relation to assistance with personal case and daily routines were taken into consideration. On the day of the inspection, one service had expressed a choice to stay in bed until after lunch and this choice was respected by care staff. Each service user has an allocated key worker who has special responsibility for the health and welfare of the resident. Both care plans seen at the time of the inspection, evidenced that the two service users selected for the purposes of case tracking had received regular Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 16 visits from both their allocated GP and practice nurse. In the case of one resident, the practice nurse visited on a monthly basis for the purposes of administering an injection. The care plan of one of the residents also indicated that they had recently received an eye examination from a local optician and had subsequently acquired a new pair of glasses. As part of the inspection process, the inspector examined the systems used for the administration and safe keeping of resident medication on Bungalow 2. Medication was found to be stored securely within a locked cupboard sited in the dining room. Medication is delivered from Boots Pharmacy, pre-dispensed in blister packs, although some medication, not appropriate to be stored in blister packs, is retained in its original packaging. The Inspector examined the way in which medication was recorded on the Medication Administration records and this was found to be appropriate. The team leader on Bungalow 2 was able to evidence to the Inspector that medication administration and storage is checked on a daily basis. There was no evidence to confirm that the systems used for the storage of medication were checked on a regular basis by a pharmacist and this should be considered to offer further protection to residents. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents living at the home can expect to be provided with appropriate information, in an accessible format, to enable them to make a complaint about the service or to raise any concerns they may have. The home was unable to evidence the action undertaken in relation to specific complaints. Residents can expect to be protected by the home’s policies and procedures on the recognition and reporting of abuse. EVIDENCE: As in previous inspections, the home was able to evidence that it has a detailed complaints procedure which is displayed at various sites within the building. Each resident is issued with a copy of the procedure in a format using pictures and symbols. Since the previous inspection, the Commission has not received any complaints in relation to this service. At the time of the inspection, the home was unable to evidence that it maintained a log of any complaints received, which detailed the nature of the complaint, investigation carried out , outcomes reached and action taken. The home was able to evidence that it had clear procedures in relation to the recognition and reporting of abuse and that staff members had received training on the protection of vulnerable adults. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 18 Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect to live in an environment which is homely and appropriate to their needs, lifestyles and abilities and is maintained to a good standard of cleanliness and hygiene. However residents can not necessarily expect certain areas of the home to be provided with furnishings of a good quality. EVIDENCE: Combs Court comprises of two eight bedded bungalows, one eight bedded house, one double and four single flats. Accommodation also includes an administration block incorporating the day care centre. There are well maintained gardens and the home is set well-back from the roadway. On the day of the inspection, the Inspector carried out an environmental tour of Bungalow 2, the house and the two-bedroomed flat. Over the past nine months, some improvements have been made to the accommodation in Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 20 Bungalow 2, including the much needed redecoration of the dining room. However, as detailed in the key inspection report dated 06 June 2006 and subsequent random inspections in September and December 2006 carpets still have not been replaced in the lounge and hallway and the damaged flooring in the dining room has not been placed. The Manager advised the Inspector that the purchase had been approved by the owning organisation but they were waiting for the arrival of samples from the suppliers. The supplier was contacted on the day of the inspection and the arrival of the samples is now imminent. The Manager advised that he hoped to have the carpets and vinyl flooring fitted by the end of February 2007. The Inspector was advised that in addition to the new carpeting for the lounge it was also scheduled for redecoration. Other areas within Bungalow 2 were maintained to a satisfactory standard of decorative order and repair. Whilst none of the bedrooms have the benefit of ensuite facilities, there is a large bathroom, a walk in shower room and an adequate number of communal WCs. The eight bedded house provided service users with very pleasant and homely accommodation which comprised of a large living room, with appropriate seating, a dining room, well equipped domestic style kitchen and a communal bathroom and walk-in shower room. The Inspector had the opportunity to look at several of the residents’ bedrooms which were all maintained to a good standard of decorative order and repair and were furnished comfortably. Each bedroom seen had been made to look very personal by the occupant and reflected their different tastes, interests and preferences. Staff allocated to work in the house also offer support to three of the residents living in the flats. The shared flat, occupied by two male residents was also very pleasant, well maintained and comfortable and comprised of two bedrooms, a lounge, kitchen and bathroom accommodation. One of the occupants advised the Inspector how much they liked living there and how pleased they were with the standard of the accommodation. All areas of the accommodation seen by the Inspector were maintained to a good standard of cleanliness and hygiene. Several improvements have been made in the last nine months in relation to infection control practices. Mops were now stored appropriately and mop heads changed on a daily basis. As part of the random inspection in September 2006, it was identified that the utility rooms on the bungalows and house did not have a designated hand washing sink. Since that inspection, the home has been able to evidence that an engineer from a sanitary-ware suppliers has visited the home to look at the possibility of providing this equipment. However, the report indicated that none of the utility rooms had the space to provide a hand-basin without structural work taking place. Therefore the existing general use sinks in each of the utility rooms has been designated as a handwashing sink only and each has been provided with a notice reminding staff that these sinks must be used for no other purpose. Staff questioned in each of the units were aware of the change of use. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 21 During the inspection, the home was able to evidence that a cleaning rota existed on each of the houses which included the cleaning of kitchen equipment. As in the three previous inspections, it was noted that one of the fridges, situated in the kitchen of Bungalow 2 was running at the slightly high temperature of 8c and therefore did not guarantee food safety. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents living at the home can expect to be protected by the home’s recruitment procedures. Whilst residents could expect to be supported by staff members who had attained proven levels of competence through NVQ qualifications, they could not necessarily expect all newly recruited staff to have received all areas of mandatory training. Recent increases in staffing levels on Bungalow 2 will ensure that the individual needs of residents are met. EVIDENCE: For the purposes of the inspection, the Inspector examined the recruitment records for the two most recently employed members of care staff. In both cases the home was able to evidence that prior to either prospective employee commencing duties, two satisfactory written references had been secured and both had been subject to a POVA Check and an Enhanced Disclosure via the Criminal Records Bureau. In the case of one of the two care staff selected for the purposes of tracking, whilst the home was able to evidence that since their employment in October Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 23 2006 they had received training in Fire Safety, Basic Food Hygiene, Protection of Vulnerable Adults and Infection Control, they had not received training in Moving and Handling. The other member of care staff who had commenced duties on 13 December 2006, had not undertaken any areas of mandatory training, although was currently undertaking the 12 week induction course. The home does maintain an overall training plan for staff which evidenced that in the last year all staff, apart from the two mentioned above, had received all areas of mandatory training. The Manager advised that a training plan for 07 is due to be produced and it is his intention to provide all staff with refresher training in all areas of mandatory training. The home was able to evidence that 28 staff out of the 51 employed have achieved an NVQ qualification. Since the previous inspection, the Manager has been able to evidence that a staff supervision structure has been put in place. This has ensured that all levels of staff receive formal one to one supervision which provides a forum for the discussion of personal development and care practice issues. Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a home which is effectively managed, although not by a Manager who has been registered with the Commission. Residents can expect to benefit from the provider’s quality assurance systems. Identified shortfalls confirmed that the home did not offer total protection to residents in relation to health and safety. EVIDENCE: At the time of the inspection, the Manager had been in post for eleven months. As highlighted in the previous three inspection reports, the Commission has still not received an application for the registration of the Manager. Section Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 25 11(1) of the Care Standards Act it is an offence for any person to carry on or manage an establishment without being registered. The current manager has achieved the Registered Manager’s Award, is currently working towards and NVQ Level 4 in Care and has been instrumental in bringing about several improvements in relation to the levels of staffing provided, the supervision of staff and hygiene control practices. The home is visited on a monthly basis by a representative of the owning organisation for the purposes of quality assurance as required by Regulation 26 of the Care Homes Regulations 2001. Written reports of these visits are being submitted to the Commission. Whilst in general the home provided a safe environment for both staff and service users, some issues in relation to health and safety were identified. * One of the fridges sited in Bungalow 2 was running at 8c which is over and above the recommended temperature for the safe storage of foodstuffs. This shortfall was highlighted during the inspections carried out on 07/06/06 and 25/09/06. * Whilst care plans examined by the Inspector for the purposes of care tracking contained individual moving and handling assessments, there was no evidence to suggest that these had been reviewed as part of the care planning process. * Fire safety records maintained on Bungalow 2 evidenced that fire alarms and secondary emergency lighting were tested on a weekly basis. However, fire records maintained in the house did not evidence that alarm systems or emergency secondary lighting had been tested since 05/01/07. * One newly recruited member of staff had not been provided with training in health and safety. * The two most recently recruited members of care staff had not received training in Moving and Handling. Combs Court Residential Home DS0000024362.V329824.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 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 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 1 x 3 x x 2 x Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15(1) Requirement The Registered Persons must ensure that each resident is provided with a plan of care which identifies individual needs and how these are to be met. The Registered Persons must ensure that each resident is provided with a risk assessment relating to his/her daily life within the home and that this risk assessment is reviewed as part of the care planning process. The Registered Persons must ensure that a log of all complaints received by the home is maintained which provides an audit trail of investigations carried out and actions taken. The Registered Persons must ensure that the flooring in the dining room on Bungalow 2 is replaced. This is a repeat requirement from 25/09/06 and 06/12/06 5 YA24 16(2)(c) The Registered Persons must DS0000024362.V329824.R01.S.doc Timescale for action 28/02/07 2 YA9 13(3) 28/02/07 3 YA22 Sch.4.11 28/02/07 4 YA24 23(2)(b) 28/02/07 28/02/07 Page 28 Combs Court Residential Home Version 5.2 ensure that replacement carpeting is provided for the hallway and lounge on Bungalow 2. This requirement was identified as part of the inspections carried out on 07/06/06, and 25/09/06. The Registered Persons must 28/02/07 ensure that fridge temperatures are maintained at 1 – 5c. This requirement was identified as part of the inspections carried out on 07/06/06 and 25/09/06 The registered Persons must ensure that all staff are provided with all areas of mandatory training, including moving and handling. 6 YA30 13(3) 7 YA35 18(1)(c)(i) 28/02/07 8 YA37 8(1) This is a repeat requirement from 07/06/06, 25/09/06 and 06/12/06. The Registered Persons must 07/02/07 ensure that an application is submitted to the Commission immediately for the registration of the current manager. This is a repeat requirement from 25/09/06 and 06/12/06 9 YA42 (18)(1)(c)(i) The Registered Persons must ensure that all staff receive training in Health and Safety. 13(5) The Registered Persons must ensure that evidence is available to confirm that moving and handling assessments are reviewed as part of the care planning process. 28/02/07 10 YA42 28/02/07 Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 29 11 YA42 23(4) The Registered Persons must ensure that evidence is available to confirm that fire alarm systems are tested on a weekly basis and secondary lighting on a monthly basis. This is a repeat requirement from 07/06/06. 07/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Combs Court Residential Home DS0000024362.V329824.R01.S.doc Version 5.2 Page 31 - 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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