Inspection on 10/11/05 for Coombe

This inspection was carried out on 10th November 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Coombe 29/06/07

Coombe 13/07/06

Coombe 23/05/05

Coombe 15/01/05

Coombe 13/07/04

Similar services:

Fairfields Country Rest Home

Fairfax House

Claremont Nursing Home

Doveridge Care Home

Dunmore

Chatsworth

Dunraven Lodge

Eastleigh Care Homes, South Molton

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

CARE HOMES FOR OLDER PEOPLE Coombe 321 Canford Lane Westbury-on-Trym Bristol BS9 3PS Lead Inspector Sandra Gibson Unannounced Inspection 10th November 2005 12:45 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 Coombe DS0000035952.V263553.R01.S.doc Version 5.0 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. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coombe Address 321 Canford Lane Westbury-on-Trym Bristol BS9 3PS 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) 0117 3772580 0117 3772581 Bristol City Council Patricia Vera Willis Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: Coombe is operated by the local authority and is registered by the Commission for Social Care Inspection to provide personal care and support for up to 30 people who are over 65 years of age and who have dementia. Coombe is situated in the Westbury Park area of Bristol in a quiet road with parkland behind and delightful views of the surrounding country. The nearest shops are 1/2 mile from the village of Westbury on Trym and the care home is located on a bus route. It is accommodated in a two-storey building with a shaft lift to the top floor. All bedrooms are single but do not have en suite facilities. There is a lounge on both floors and a spacious dining room on the ground floor. There are several toilets near to communal areas. The building itself is based upon a long corridor and does not lend itself to small group living. The garden has a ramp making it accessible to wheelchairs, and is secure. It also has a pergola, garden table and chairs for residents to use in warm weather. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place midweek between the hours of 12.45pm and 4.15pm. Evidence was gathered from: talking to and observing residents, talking to three relatives, talking to the manager, talking to staff, observation, viewing the premises, examining records and policies and procedures. What the service does well: What has improved since the last inspection? Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 6 The system of providing residents with a written contract /statement of terms and conditions has improved since the last inspection which ensures all residents are informed of their rights when moving to Coombe. The support and training in place to meet residents’ individual mental health needs has improved considerably since the last inspection. This ensures that residents who have been assessed as requiring personal care as a result of dementia and mental health needs may be cared for within the limitations of the home’s registration category. Arrangements for protecting residents from harm have improved considerably since the last inspection. These measures ensure that residents are protected as far as possible from risk or harm. What they could do better: Information provided to prospective residents needs to be updated as it is still not wholly accurate and could be misleading. The system of how and when to provide this information needs to be further developed to ensure that prospective residents and their carers have the necessary information to make an informed choice about where they choose to live. The medication administration system has not improved since the last inspection. It is currently not satisfactory and must be immediately improved to prevent residents being placed at risk as a result of poor record keeping. If improvement is not seen at the next inspection enforcement action may take place. The residents’ health and safety continues to be at potential risk due to the deterioration of the exterior of the care home. The staffing situation remains very poor as Coombe continues to rely on a high level of agency staff, which may prevent residents receiving continuity of care. Staff training for permanent staff has improved but there continues to be gaps in training for agency staff which may result in residents not being in safe hands at all times. Support to permanent care staff has improved since the last inspection However support to agency staff needs to be developed to ensure that they Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 7 well supported to provide personal care to these residents who have specialist needs as a result of dementia and their mental health needs. 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. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 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 Coombe DS0000035952.V263553.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Information provided to prospective residents needs to be updated as it is still not wholly accurate and could be misleading. The system of how and when to provide this information needs to be further developed to ensure that prospective residents and their carers have the necessary information to make an informed choice about where they choose to live. The system of providing residents with a written contract /statement of terms and conditions has improved since the last inspection which ensures all residents are informed of their rights when moving to Coombe. The support and training in place to meet residents’ individual mental health needs has improved considerably since the last inspection. This ensures that residents who have been assessed as requiring personal care as a result of dementia and underlying mental health needs may be cared for within the limitations of the home’s registration category. Residents’ placements continue to be fully reviewed following their admission to the home . This allows residents and their relatives to make sure that Combe can meet their individual needs. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 10 EVIDENCE: The statement of purpose and service users guide were examined It was noted that the information was clear and concise. However there are still gaps in the information held including information on mental health support provide and recent training. The manager confirmed that minor amendments were due to be made following the next review of the documentation due in December 2005. During the course of the inspection it came to the attention of the inspector that some family members said that they had not received the Statement of Purpose and Service users guide when viewing the home on behalf of their relative. This was discussed with the manager who said that she had provided the information herself on this occasion. However, there was no record of this documentation being provided to any relatives. A sample of statement of terms and conditions was seen during the course of the inspection and were noted to be up to date and accurate. The manager has recently completed training in working with people with mental health and emotional support needs. She informed the inspector that she had found the course very beneficial and that she was now planning to develop her skills further by attending a one-year City and Guilds Community Mental Health Course. It was also pleasing to hear that the staff team are also currently involved in training in working with people with mental health needs which is being provided by the Mental Health In reach team. This training is to be conducted over a number of weeks and was introduced after a serious of incidents involving a resident who has a history of dementia and a recent history of challenging behaviour. There are also plans for the staff team to attend mental health training provided by Social Services and Health starting with a rolling programme in February 2005. There was written information in place to confirm that all new residents are subject to a four weekly review prior to a placement being made permanent. It was noted that the resident, resident’s representative, placing social worker, and key worker are all consulted during the review. It was noted that this review may take place earlier depending on the residents assessed needs and in some cases a temporary placement may be extended to ensure that a residents needs can be fully met in the home and that Coombe is the most suitable placement for each individual. Two relatives seen at the time of the inspection confirmed this information. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9,10, There are systems in place to ensure that residents recive the appropriate health care at the right time .This ensures that the physical and mental heath needs of residents are well met. The medication administration system has not improved since the last inspection. It is currently not satisfactory and must be immediately improved to prevent residents being placed at risk as a result of poor record keeping. The standard of personal care provided to residents at Coombe is good . This ensures that residents are treated with respect and that their right to privacy is up held EVIDENCE: Records confirmed that health professionals such as General Practitioners, district nurse, community psychiatric nurses and chiropodists are contacted at the appropriate time. There was evidence of multidisciplinary working taking place on a regular basis. Equipment was observed to be in place to prevent pressure sores in residents who were at risk. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 12 It was noted that one resident had sustained a scald prior to admission and the care staff had observed this immediately and urgent arrangements had been made for the District Nurse to treat the area. One relative spoke about her mother having a mouth ulcer and how quickly the staff had found this out and treated it. This same relative said “how quickly the staff notify me if mum has a fall. They always keep me abreast of what is happening”. It was noted how the Mental Health In reach Team were now providing support and training to the staff as previously discussed. This team is made up of a psychologist and a community psychiatric nurse and they currently visit the home twice week for two hours. It was observed that the support and training been of particular benefit for the staff caring for one resident who has been displaying symptoms of challenging behaviour. The documentation in place was examined. It was noted that a log sheet of challenging behaviour was maintained so that staff were aware of any triggers which may cause this behaviour and what action to take. Up to date risk assessments were also noted to be in place for the protection of the resident, other residents and staff. Through out the inspection it was observed how the management and staff team treat all residents with respect and dignity and how independence is encouraged. Three relatives seen at the time of the inspection confirmed this. One agency member of staff consulted stated, “all residents are treated with respect and the staff actually care”. S/he also said “it is like a home, every body knows everybody”. One relative said that sometimes her/ his father has not had a shave when s/he visits, but this is often because he does not want one. S/he said that he is able to shave himself and she has told staff to continue to encourage him to do this activity himself during the recent review. On examination of medication administration records it was noted that some tablets had been given out of order which resulted in the administration sheet being misleading. It was also noted that there were gaps in recording. Consequently, it was not possible to confirm if one resident had received his medication or not that day. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Coombe continues to provide residents with the opportunity to experience a stimulating and varied life where various informal activities are regularly made available. Visitors are made very welcome and meals are well managed and provide daily variation, good nutrition and social contact for people. EVIDENCE: On the day of the inspection the inspector had the opportunity to see three residents who had been on an outing with two members of staff. It was noted that they had enjoyed a pub lunch together. One resident told the inspector how much he had enjoyed the occasion as he had had the opportunity to discuss his previous employment with a male member of staff who knew what he did. It was noted that twelve residents were going out that evening to watch the local amateur dramatics perform Golden Oldies. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 14 There was information in the activities book to confirm that all residents were receiving one to one time with their named carer, two residents had been accompanied to Weston Super mare and two residents had been to Bristol Zoo. Groups of residents are also encouraged to join in with activities such as making egg and cress sandwiches, painting or making pots. An activities coordinator supports these activities. Musical entertainers visit Coombe on a regular basis and the “Pat” dog Scheme visitor visits the home. A further trip to the Pantomime is planned for Christmas Time. Coombe have a library of videos that are appropriate for the older age group accommodated in the home. The home holds an annual summer and winter fete and members of the local community are invited. This was confirmed in the relatives meeting minutes dated 19thy September 2005. It was noted that all relatives are invited to organised functions where food, drink and entertainment are provided. There is a church service that takes place on a monthly basis. Reflexology and aromatherapy sessions are held once a week in addition to visits from the hairdresser. The staff and management team confirmed all of this information. It was also noted in the relatives meeting minutes that concern had been raised about the available space for visitors. The manager had explained that the bar lounge on the ground floor is for visitors to meet with a relative in private and if this room was not available then an alternative room may be found including the resident’s bedroom. Tea and coffee are always available either by asking a member of staff who will either make it or provide the provisions for relatives to make a drink themselves. Relatives may also have a meal with the resident they are visiting. It was noted that vegetarian meals were discussed at the relatives meeting. Relatives told the manager that they feel only egg and cheese dishes were offered as an alternative. The manager explained to the relatives that when it was all meat on the menu then a vegetarian alternative was also available. It was understood that either a freshly cooked vegetarian dish would be provided or the cook has now ordered individual lunches from the frozen foods company and these were always available. A four-week menu is provided and this is on display in the home for the residents to see. A copy is also available for relatives to see. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 15 The staff team have recently organised theme days in the home. One day in September was a French theme day and another day in October was a Caribbean style day. The staff told the inspector that both days were very successful and included tasting food from these places, staff decorating the home and the appropriate music was played. A member of the management team said on each occasion the staff had made the food and that she had helped prepare and make the Caribbean food, which the residents thoroughly enjoyed Comments from residents included “I am very happy here. There are lots of people to talk to,” “ I like it here”, “staff are very nice and caring”. A relative said, “My mum has lived here for two years. It is a happy atmosphere. Staff are very supportive and pleasant. Residents like a smiling face. There is enough going on for residents. The entertainment is good. I have been present and joined in with the music. The food is good, always looks nice and is well presented. The Christmas Celebrations are very good too”. Another relative said, “The activities are good here. They are meeting social needs very well. One member of staff is encouraging my relative … to help in the home’s garden. The staff cook my relative a meal at night if he is not able to sleep.” A third relative said, “My mum has picked up since she moved here. She enjoys the company and is happy to join in with things. The food looks okay too. I have not tasted it but I saw lasagne and cheese on toast snacks, both looked okay.” An agency member of staff said, “it is a great place to work. There is lot going on for residents. There is a Christmas Party planned where relatives are invited, a Christmas Carol Service and a trip to Harry Ramsdens is planned.” Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Arrangements for protecting residents from harm have improved considerably since the last inspection. These measures ensure that residents are protected as far as possible from risk or harm. EVIDENCE: There have been no complaints since the last inspection. There was written evidence of compliments the manager had received from relatives about the care provided to residents. Relatives meetings are held every four months. A copy of the last residents meeting minutes dated 19th September 2005 were available on the relatives notice board. It was noted that relatives had raised some concerns during this meeting, which had been appropriately dealt with about the manager. Residents who were able to said that they felt the staff listened to them and that they would talk to somebody in the office if they had any concerns. All relatives seen confirmed that they would speak to the manager if they had any concerns or wished to make a complaint. There have been several allegations of abuse involving residents with other residents in this care home in the last year. All permanent care staff and management staff have received protection of vulnerable adults training in line with the NO Secrets in Bristol guidance (Local Authority Adult Protection Guidance). Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 17 It was pleasing to note that all management staff have gradually gained experience of who to contact and when both during the day and out of hours and have become more familiar with the process. This information is confirmed in the Incident reports sent to the Commission for Social Care Inspection and in the adult protection meetings. Strategies and training have also now been put in place to further reduce the risk of residents harming other residents in the home. For example all bedroom doors are now alarmed to assist night staff to establish which residents are out of their rooms and can be offered assistance back to bed where appropriate. It was noted that this is a form of mild restraint and that there is no agreement in place from the resident or representative. It was also noted that there is no risk assessment in place about the use of these alarms with a result if may be restricting some residents freedom and privacy. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. A comfortable, clean, safe standard of accommodation is provided internally for the residents of Coombe. The residents’ health and safety continues to be at potential risk due to the deterioration of the exterior of the care home. EVIDENCE: In general, the environment continues to be is well maintained and suited to residents’ needs Disabled access is available in this home. Coombe is decorated and furnished to a standard that creates a reasonably comfortable homely atmosphere. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 19 There is an ongoing project in the home to create a more homely environment, which is partially met. This was confirmed in the Relatives meeting minutes dated 19th September 2005. One relative commented that she had seen many improvements over the last couple of years and that it is a much nicer environment to what it had been before the main hall at the entrance to the home had been partitioned. The manager said she was planning to buy more table nests and put more pictures up to make the main hall. There is also a programme of redecoration and refurbishment to further improve the environment. However, it was noted that an email had been sent to the manager in October 2005 to put the decoration and work to the kitchen on hold and no explanation given. The woodwork around the window frames has deteriorated further since the last two inspections and now looks unsightly. This has been reported to the estates manager, but no further progress or notification has been made despite requirements about this work being made in previous reports. It was noted that major emergency maintenance work that was required to be completed on the drains at the rear of the building has now been completed. There are a number of small lounges through out the care home which residents were seen using and appeared comfortable and relaxed. It was noted that the main entrance hall appears to be the most popular spot to sit where residents can see what is happening around them and who is coming in and out. Residents’ bedrooms looked homely and were personalised with residents’ personal possessions and furniture. However, it came to the attention of the inspector that all bedroom doors are now alarmed to assist night staff to establish which residents are out of their rooms and can be offered assistance back to bed where appropriate. It was noted that this is a form of mild restraint and that there are no agreement in place from the residents or their representatives. It was also noted that there are no risk assessments in place about the use of these alarms with a result they may be restricting some residents’ freedom and privacy. The toilet and bathroom facilities are sufficient to meet the needs of the residents and the toilet doors have all been painted in red and sign posted following consultation with Dementia Voice. There were no unpleasant smells in the home and the rooms were cleaned to a high standard. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 The staffing situation remains very poor as Coombe continues to rely on a high level of agency staff, which may prevent residents receiving continuity of care. Staff training for permanent staff has improved but there continues to be gaps in training for agency staff which may result in residents not being in safe hands at all times. EVIDENCE: On the day of the inspection the staffing levels were appropriate to meet the needs of the residents, but as noted at the last inspection there was a higher proportion of agency staff than permanent staff on duty. The manager informed the inspector that there was five care staff vacancies, which had recently increased following the dismissal of two night staff following an investigation. Day staff has now filled these hours but that has now left gaps in cover during the day. The manager informed the inspector that regular agency staff are used where possible. The agency staff seen at the time of the inspection confirmed this. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 21 There was no information to confirm that these agency staff members had conducted the statutory training (Manual handling, basic food hygiene, fire safety, first aid and protection of vulnerable adults) or any specialist training such as dementia care and mental health training to ensure that they have the appropriate experience to work in this care home. NVQ training for both domestics and care staff is on going, but the home will not reach the national minimum target of 50 of the care staff being trained to NVQ2 by December 2005. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,37, The residents and staff team continue to benefit from an experienced manager who has encouraged an open style management approach. Support to permanent care staff has improved since the last inspection However support to agency staff needs to be developed to ensure that they well supported to provide personal care to these residents who have specialist needs as a result of dementia and their mental health needs. The system for accessing records that must be available for an inspection is good and the majority of records were found to be up to date and accurate. This protects residents’ rights and best interests. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 23 EVIDENCE: The manager was available on the day of the inspection, records confirmed that she has completed NVQ4 (management of care) and has recently completed a registered managers award. She has completed training in dementia care and as discussed previously has completed training on working with residents with mental health needs and is planning to do a more intensive course City and Guild On Community Mental Health which takes one year. This is good practice. All staff and relatives consulted confirmed that the manager continues to be very approachable and supportive. Regular relatives meetings continue to take place. Minutes from the last one dated 19th September were available for residents’ relatives and staff to see. The manager confirmed that staff supervision was now taking place on a regular basis for all permanent members of staff. A sample of records that are required to be available for inspection were found to be secure and well maintained Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 24 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 2 3 X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 2 3 3 2 3 STAFFING Standard No Score 27 1 28 1 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 3 X Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 25 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 op1 Regulation 6 Requirement Timescale for action 31/01/06 2. OP9 13(3) 3. OP19 23(2)(b) 4. OP22 13(4) The statement of purpose/ service users guide must be reviewed to include information about residents who have long term mental health needs. This requirement is ongoing from the last inspection 13th May 2005 The Medication administration 10/11/05 system must be reviewed. All medication must be accurately recorded immediately following administration A programme of maintenance 31/01/06 work including: Plans to repair / repaint the window frames refurbishment of the kitchen and detail of redecoration must be sent to the Commission for Social Care inspection and reasons for any delay must be put in writing Emergency alarms must not be 10/02/06 fitted to all residents’ doors as a matter of cause. They must only be fitted in an emergency following a multidisciplinary meeting. Any resident and their representatives must be then consulted about the plan to DS0000035952.V263553.R01.S.doc Version 5.0 Coombe Page 26 5. op28 18(a) 6. op30 18(1)(b) 7. OP28 18(1)(a) 8 OP36 18(2) attach an emergency alarm to the residents bedroom door and written consent regarding the use of this equipment must be obtained. A risk assessment must also be completed on each individual resident and this risk assessment reviewed on a regular basis Residents must receive care provided by suitably qualified experienced staff. The registered manager must ensure that all agency staff have the appropriate qualifications and experience before the agency member of staff works in the home. A written record of each agency staff training and experience must be available for inspection Residents must be provided with continuity of care. An action plan of how this is going to be achieved must be sent to the Commission for social Care Inspection An action plan of how the care home is going to achieve a minimum ration of 50 trained members of care staff (NVQ 2) on every shift care staff must be provided to the Commission for Social Care Inspection All staff including regular agency staff must receive one to one supervision at least six times a year. The registered manager must ensure that this is provided to agency staff when they provide care to the home 30/01/06 10/02/06 31/01/05 31/01/06 Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 27 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 OP1 Good Practice Recommendations A record should be held of any service user /relative or representative to whom the Statement of Purpose and service user guide is provided. This information should include the name of that person, who they are in relation to the service user and the date the information was provided. Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 Coombe DS0000035952.V263553.R01.S.doc Version 5.0 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!