Inspection on 17/07/06 for Coombe End

This inspection was carried out on 17th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coombe End 06/06/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Coombe End 184 Hucclecote Road Gloucester Glos GL3 3SJ Lead Inspector Kath Houson Key Unannounced Inspection 17th July 2006 & 15th September 10:00 Coombe End DS0000067015.V302598.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 Coombe End DS0000067015.V302598.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. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe End Address 184 Hucclecote Road Gloucester Glos GL3 3SJ 01452 617193 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) www.brandontrust.org The Brandon Trust Mrs Jennifer Phyllis Gainpaulsingh Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Coombe End is a large two-storey house in a residential area about two miles from Gloucester city centre. The service provides accommodation for adults with learining disabilities. The home is centrally locateded within the community of Hucclecotte close to local amenites. There are bedrooms on the first floor and further bedrooms on the upper floor. All the room (s) are adapted to meet the needs of the residents and this includes specialist equipment when necessary. The home is run by Brandon Trust and Advanced Housing manage the property. Accurate information about fees was not obtained during the inspection but will be supplied separately by the organisation in due course. The home is able to provide a Statement of Purpose, terms and conditions and Service User Guide on request to any potential residents. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The unannounced inspection took place over two separate days and was concluded one day in September 2006. The manager agreed with CSCI piloting of a new observational tool in the home. Part of the trials are taking place at locations around the country. Since this was a pilot the outcome of the observation does not form part of the judgements made in the report. The registered manager was unavailable during the first half of this inspection, and was available on the second part of the inspection and able to assist and provide all relevant documentation on request. Twenty one-key and one-non key standards were examined. This included an examination of documentation; two service users were case tracked, a tour of the environment and a short discussion with a staff member. A short succinct feedback was given to conclude the inspection visits. The home has had a recent change of service provider from Mayfield to Brandon Trust and therefore much of the documentation was being transferred over. The inspector would like to extend her thanks to the service users, staff and management for their assistance with the inspection. What the service does well: What has improved since the last inspection? The home would appear to be managed well. Many of the recommendations from the last report have been carried out. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 7 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 Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good admission and exit process for service users to enter and where necessary leave the home. Good support is provided and a detailed account is documented in the resident’s care plan. EVIDENCE: The home has an established admissions procedure that is currently being used to assess the suitability of a potential home. Case tracking confirmed that good practice exists. A senior support worker and key worker made arrangements to visit a prospective service to obtain information that is to be shared with the service user (s). Other professionals were available to provide assistance to ensure that the appropriate support had been maintained. The individual aspirations and needs are taken into account and shared with the potential home. For example, an assessment was made of the service user’s ability to manage a flight of stairs. A written account provided detailed evidence and demonstrated the reaction of the service user in the potential home. The manager has arranged that the service user have an extended visitation time to include overnight (s) stays in order to obtain a fuller snap shot of the potential place of residence. This gives the service user the opportunity to sample the potential home before making an informed choice about their place of residence. The home, at the time of inspection had received no new referrals. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 9 The National Minimum Standards in this instance were particularly about the processes for service user (s) moving into the home. This was the home’s exist procedure, in which steps were being made to ensure that service user (s) are well placed and effective support is provided. Standard two in this case may not apply but the manager explained the admissions process and thus able to provide support to service user (s) who wish to move on from the home. The manager said that the Statement of Purpose and the Service User Guide is currently being updated/reviewed and will forward copies into the Commission. The terms and conditions for the home will need to be personalised and individualised. Completed documents will need to be sent to the Commission within 28 days and a requirement has been made to ensure that this is conducted. The registered manager shall compile a written Statement of Purpose, and Terms and Conditions in respect of accommodation to be provided for service users and to include the amount and method of payment. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good care plan frameworks exist and provide guidelines on how to provide care for residents with complex needs. Each care plan is individualised and regularly reviewed. Staff are skilled at understanding what is being communicated through the use of object of reference. Risk assessments are in place to ensure that residents participate in activities in a safe manner. EVIDENCE: Two care plans were examined and contained information on how residents’ needs are met. The staff team use a form of total communication such as the use of body language for instance to assess the needs of residents. For example a resident would make a request by picking up an object also known as ‘object of reference’. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 11 The staff team are skilled in understanding the service users and provide support, which assist service users’ to make decisions. For instance during the second visit the staff team provided support when a service user demonstrated their wish to go out into the community. This form of communication provides and informs care staff about decisions residents make. This approach to communication can be seen as good practice as this helps promote independence and encourage residents to communicate in a creative way. The staff team are caring and respectful this was observed throughout the inspection where there was regular and constant staff interaction with residents. Risk assessments were available for activities and general routines such as appointments were available in care plans that were case tracked. Risk assessments are planned with other health professionals to ensure that residents are risk assessed in a manner that promotes safety. For instance protocols were in place to inform staff members about the frequency of a resident’s epilepsy seizures. Risk assessments encourage residents to participate in independent lifestyles within the home and with support external to the home. Residents regularly take part in activities that encourages them to become part of the local community. Activities include, regular meetings at the local luncheon club. The home also has access to the local shops. Risk assessments were available in the case tracked files and contained short reports for Community Learning Disabilities Team. The home has access to other health professionals and will utilise when necessary. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ have individual needs and preferences of activities they enjoy and structured activities are arranged to ensure that residents are part of the local community. Support is provided for service users to maintain close contact with important people in their lives, thus promoting their wellbeing. Residents are offered a varied diet that respects their preferences and needs and support is provided during mealtimes. The home provides a good range of balanced dietary choices. EVIDENCE: A structured individualised activities programme is in place for the residents. The activities include visits to the Rainbow Club every evening. Some of the residents attend the local luncheon club. Many of the other residents like to go Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 13 out for drinks to the local pub and shops. The home additionally has access to Treasure Seekers that is a Christian organisation which provides entertainment every evening. The manager arranged structured activities that are based on the rota to ensure that residents have regular opportunities for outings. The arrangements for the activities are not entirely person centred and may need addressing. Careful planning of activities is based on the availability of staff that are skilled car drivers. Although the residents have access to activities there is room for improvement to enhance the person centred approach in regard to activities. The home also provides annual opportunities for holidays. One service user was preparing to leave for their holiday on the day of the second inspection visit. It became apparent during the inspection that service users prefer their own space and members of staff respect this and provide care accordingly. Residents’ care plans are individualised and contain their ‘likes’ and ‘dislikes’. Service users’ activities were recorded in the handover sheets and showed regular outings. On the second day of the inspection one resident was going out with members of staff. It would appear that staff members support residents on a ratio of two to one basis when out on activities and holidays. This is good practice to ensure that residents are kept safe. The staff team support the residents to become part of the community. This promotes independence and assist in the making and maintaining friendships external to the home. The staff team demonstrate caring and respectful qualities towards residents and called each resident by their name in a thoughtful manner. The daily routines promote independence and are individualised. This was evident in the care plans. Many of the staff team have stated that the residents have made progressive steps in their communication. For instance one service user verbalised more and was able to say a few words. During the inspection the staff team frequently conversed with the residents. The communication sheet is used throughout and events were noted. The residents are able to choose what they wish to eat. Handover sheets contain what each resident has eaten throughout the day. The home has no set menus and food shopping is individualised. During the day of the first visit lunchtime was observed the staff provided support in a respectful manner. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal care needs are recognised and promote dignity. Appropriate support is provided with healthcare needs that enhance resident’s wellbeing. An improvement to the administration of medication now exists which would minimise the potential for error. EVIDENCE: Care plans describe the support residents require with personal care and how this was to be offered. Resident’s preferences are made via support of their choice. This is based on the understanding the staff have of the resident’s communication skills and this promotes their independence. The staff were able to explain how they manage to support residents’ with their preferences. Files that were case tracked demonstrate clear guidance for managing behaviour patterns expressed by the resident (s). The use of communication and handover sheets describe the resident’s wellbeing. Residents have access to other health professionals this was evidenced via a district nurse report. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 15 The administration of medication procedure has improved and was examined. The shortfalls that were identified during the previous inspection have been addressed. All members of the staff team are qualified to administer medication and now use blister packs, which ensures that correct doses are given. Additionally, the home has a rota, which includes that staff sign when the medication keys have been handed over to other members of staff. This process ensures that the staff team can keep track of the medication keys. A medication round was observed during the current inspection and demonstrated that safe procedures were being practiced in the home. Members of staff have a designated area that is equipped and includes good ventilation and hand washing facilities. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure which includes pictorial and textual format. The home has clear procedures when dealing with service users finances. EVIDENCE: The home has had no formal complains at the time of the current inspection. There was however a number of comments made about the unsuitability of the environment. This has been highlighted in this inspection report. Brandon Trust has provided the home with new complaints procedure that is in keeping with the provider’s format but is still under review. The home’s original procedure was implemented in June 2005. The home has good links with service users’ families in which they feel valued. Additionally, the manager encourages friends and representatives to advocate on the clients behalf. The home has a complaints procedure, which is in pictorial format with a mixture of simple text and the use of pictorial Makaton messaging. This can be seen in the home’s service user guide. The manager ensures that the staff team are regularly updated with information to safeguard service users from abuse. Training record seen as evidence and is provided by the providers of Brandon Trust. The manager additionally has a system where service user’s finances are regularly checked throughout the day. The Trust’s policy on safeguarding service users and the whistle blowing procedure appeared to be comprehensive. A discussion with a member of staff demonstrated an awareness of protection procedures. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely and adequate environment is generally maintained although some parts of the building and décor need attention in order to promote service users’ comfort and wellbeing. The building is not ideal as a care home. EVIDENCE: Coombe End is a residential care home for ten adults with learning disabilities. The home is situated two miles from the centre of Gloucester. The home is a large detached Victorian house with its own private rear garden, which is secure and has been adapted to meet service users needs. The home is close to local amenities and services. The home is institutionalised in essence in that some aspects of the building lack homeliness and present hazards. The home has comfortable furnishings and the fixtures and fittings are adequate. The bedrooms that were examined were clean and personalised. Each room has stable doors fitted to observe the service users without causing too much of a disturbance. These types of doors make the home less homely and add to the institutionalised feel of the home. The living quarters of the home present as homely, but this is not consistent throughout the home. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 18 Additionally, on observations it was evident and with discussion with the staff team that the service users prefer their own company and use different parts of the home. The environment can provide that aspect of care. However it does make supervision difficult. There are a number of issues about the home that need to be addressed and have been highlighted during the inspection. • The home has not had a cleaner for several months and the cleaning is left to the care staff. This is not a realistic goal, as the residents require supervision and require regular support from the staff team. See previous inspection report. Additionally, to maintain the home in a clean and orderly manner is a sizeable task. A cleaner would be helpful to maintain the cleanliness of the home. There are a number of cracks on the internal walls to the parts of the home. Alternative plans are being discussed as to the suitability of the home. In addition there are plans to convert part of the home into a contained bungalow for a resident. This plan is under discussion as the building is not ideal for long-term use. The manager has stated that getting repairs completed is difficult. It is important that repairs are completed on time, to ensure that the residents live in a safe and secure environment. Some areas need attention so that it is a more comfortable and suitable place to live. • • The kitchen is a good size with a well-stocked pantry. The home had good amount of fresh fruit and vegetables that were seen on the day of inspection. The home has an organised laundry room. The home also has an adequately equipped sensory room which service users enjoy and often spend their time there. The home provides accommodation for residents but the building is not ideal as a residential home for service users. Discussions are underway to find alternative solution to the accommodation and the providers are seeking a long-term plan. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a staff team that is competent caring and considerate to service user needs. Good recruitment procedures are in place to ensure that service users are safeguarded from potential harm. EVIDENCE: During the inspection there was evidence to show that there was a high sickness level. This was seen from the rota for April/May/June ‘06. The manager was able to produce the sickness record with the aim is to keep abreast of this situation. It was evident that the service users gain the support that they need from a staff team that is competent and caring. Evidence was seen from the care plans, feedback forms and staff interaction. The staff team are long standing and committed and trained to their standard of expertise. The comments cards for the care workers read very positively stating that there is enough support from the care home to do the task. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 20 The main comments made were about the environment and that the service users themselves do not really get on with each other. This could pose a high level of stress for both staff and service users’. For instance, comments that were made for example, that it would be a good idea that each service user to have their own transport as the staff have to consider the client mix when organising activities. The staff were able to provide client-centred approach in some instances during mealtimes staff were able to provide 1:1 according to their needs. It was witnessed that the staff members treat each client as an individual with kindness and respect. During the inspection dignity was maintained at all times. The manager ensures that recruitment procedures are followed according to the homes recruitment practices. This was evident during the examination of staff files that provided added protection of service users. The staff team provide twenty-four hour care from competent staff that receives regular updated training. The staff training files was examined and included evidence of mandatory and specialist courses such as epilepsy being booked and formed part of the new training programme for 2007. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed effectively and provides a safe and secure environment which promotes positive outcomes for the service users. A regular quality assurance framework is in place, which assists the service to identify areas for improvements and keeps abreast of what the service does well. The home has appropriate systems in place to maintaining the health and welfare of both service users and staff members. EVIDENCE: The manager has policies and procedures that are personalised to the home and the daily operational running of the home does not affect the clients but ensures that the residents are safe and promote their independence within a Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 22 safe and secure environment. Health and safety documents were examined and safety checks were regularly being done to standard. The registered manager is a qualified nurse who has many years experience with working with individuals with profound and multiple learning disabilities are currently managing the home. The manager has been working at the home for several years and fosters an atmosphere that is inclusive and open. This encourages the residents to actively exercise their independence. Feedback from the relatives and representatives are positive and state that the staff team work in partnership with the people in care and families are excellent. The residents have severely profound and multiple learning disabilities but the outcomes for the service users’ are good. The home has regular quality assurance and self- monitoring to ensure that the provision of service is maintained to a good standard. The manager has regular staff meetings in which staff have the opportunity to discuss issues and share improvement ideas. The previous inspection highlighted an issue with asbestos that has now been isolated to one spot and made safe. Although this will need to be documented and a report obtained from the Housing Association to confirm that this work had taken place. A requirement has been made to request that the report be located and a copy sent into the Commission. Advance Housing who are discussing alternative place for accommodation for the service users’ is managing the home. Advance Housing are currently involved in discussions with Brandon Trust and other stakeholders about providing alternative accommodation for the service users living in the home. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 23 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 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 24 No 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 YA1 Regulation 5 Requirement The registered person produces an up-to-date statement of purpose setting out the aims and objectives and philosophy of the home, its service and facilities and terms and conditions in respect of accommodation to be provided for service users to include the amount and method of payment of fees. The registered manager ensures as far as possible that unnecessary risks to health and safety of service users are identified and so far as possible eliminated. In regards to the asbestos, if the manager could locate a report and send in a copy into the Commission Timescale for action 20/12/06 2. YA42 13 (4)(c) 06/12/06 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 Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 25 1. YA30 The premises are kept clean and hygienic throughout. Consider the regular use of a cleaner who would be able to maintain the general upkeep of the home. Coombe End DS0000067015.V302598.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 End DS0000067015.V302598.R01.S.doc Version 5.2 Page 27 - 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!