Inspection on 06/06/07 for Coombe End

This inspection was carried out on 6th June 2007.

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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coombe End 17/07/06

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 Mr Paul Chapman Key Unannounced Inspection 6th and 21st June 2007 09:00 Coombe End DS0000067015.V337435.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.V337435.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.V337435.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.V337435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th July 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 learning disabilities. The home is centrally located within the community of Hucclecotte close to local amenities. 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.V337435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over 2 site visits. At the first visit the manager was not on duty and the inspector arranged to return to the home at a later date to discuss issues including staffing, training and other issues specific to the manager. On arrival at the first site visit two staff were on duty (1 person was a member of agency staff). Both staff were busy supporting people with personal care and breakfasts. The inspector completed a tour of the premises downstairs including the garden to the rear while staff were busy. Once the regular staff member was free they showed the inspector around the second floor of the home. The personal and care files for each of the people living in the home were examined in detail with the inspector looking at needs assessments, care plans, risk assessments and other personal information. Other records to be examined included personal finances, medication records, menus and involvement of other professionals. Staff interactions with people living in the home were observed and seen to be positive and led by people’s needs. Conversations with staff showed that they had a good knowledge of peoples needs, and the day-to-day procedures that help to maintain peoples safety. What the service does well: What has improved since the last inspection? It was difficult to identify specific areas that had improved but the staff team have maintained a good level of service under difficult circumstances. Coombe End DS0000067015.V337435.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. The summary of this inspection report can be made available in other formats on request. Coombe End DS0000067015.V337435.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.V337435.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriately trained staff assess people’s needs and information is available about the home and the service it provides. EVIDENCE: No new people have been admitted to the home since the previous inspection. A requirement of the previous inspection report was that the registered person was to produce an up-to-date statement of purpose that included the following information: • The aims, objectives and philosophy of the home. • The service and facilities provided. • The terms and conditions of residency. • The fees. • Method of payment. This has now been achieved. Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 9 People’s personal files contained statements of the terms and conditions signed by their representatives. Presently there are 3 people living in the home. All 3 people’s personal files were examined in detail and provided evidence that each person had been assessed by the staff in the home. Coombe End DS0000067015.V337435.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. All of the people have care plans in place to meet their needs and enable staff to meet their care needs consistently. Other information available in people’s files enabled the reader to have a good understanding of the person in question. Risk assessments are in place to minimise potential risks. Some documents (life histories, strengths and needs, and other documents) that provided general information about a person were in need of review. EVIDENCE: As mentioned previously the care files for all 3 of the people living in the home were examined in detail. The files provided care plans covering the following areas: • Communication • Car • Personal Care Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 11 • • • • • • • • • Kitchen Eating and drinking Behaviour Health Social and Leisure activities Mobility Continence Laundry Sexuality Two of the files examined showed that all of the care plans were reviewed monthly, whilst the care plans in one file had not been reviewed since January this year. This was brought to the attention of one of the senior staff on duty who confirmed that reviews should be completed monthly. A discussion took place about the need for monthly reviews and the inspector recommended that where peoples needs were not changing regularly that maybe reviews should be completed 6 monthly (or more frequently if appropriate). In addition to the care plans in each file a number of other documents were available building a picture of the person’s life. An example of the documents found includes: • A pen picture • Twelve activities of daily living • Strengths and weaknesses • Likes and dislikes • Life history • Intensive interaction plan • Communication tools • Lifting and handling assessments • Traffic light system for behaviour management (it was noted that one person’s plan was from 2002 and in need of review) Examining people’s daily notes, personal files and from speaking to staff the inspector was provided with evidence of people being able to make decisions for themselves. Where a person has been unable to make a decision for themselves previously the home have used a “best interest” document which provides a transparent system when staff are making a decision for someone. A recommendation with using the best interest document is that they are reviewed regularly. Each of the files examined contained risk assessments. The detail and number of completed risk assessments varied from file to file. This is an area that the manager should review to ensure that all areas of each person’s life has been risk assessed. Examples of where shortfalls were identified included where the kitchen presents risks to people and when they access the local community. It becomes a requirement of this inspection report that risk assessments are Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 12 reviewed to ensure that all people have detailed risk assessments for each area of their life. Observations of the relationship between the staff and people in the home were seen to be positive and led by people’s needs. Some of the documents seen in people’s files had been written a number of years ago and the inspector spoke to the manager about the need to review these documents. Examples of this includes life histories and strengths and needs. Coombe End DS0000067015.V337435.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, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People lead active individual lifestyles with the support of the staff team. Family and friend are welcome to visit the home and staff support people to do this where required. People benefit from a varied diet but methods to empower choice are limited at the moment. EVIDENCE: None of the people living in the home have set day care provided in a day centre. Staff explained that activities vary from week to week depending on what the person would like to do. Usually there is a driver on duty. The inspector spoke to staff and examined the daily notes which confirmed that the following activities took place. • Picnics in the summer Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 14 • • • • • • • • Eating out in Pubs and restaurants Attending a luncheon club Attending social clubs Going to the cinema Visiting the circus Hydrotherapy Using a multi-sensory room Going to the local shop to purchase a paper A number of the activities are completed on a 1 to 1 basis. An issue noted by the inspector was that sometimes staff were not completing the daily notes sheets thoroughly, leaving some areas blank. This was brought to the attention of the senior support worker who agreed staff should be giving an explanation, was an activity offered? The box should not be left blank. All of the people have been on holiday within the past 12 months. People at the home have limited contact with members of their family. Members of one person’s family visit regularly and staff spoke about having a good relationship with them. Staff explained that they draw up a basic menu based on their knowledge of what people like to eat, some staff have worked with the 3 people for many years. Staff explained that if people do not like what’s on the menu they can choose something else. Staff stated that they intend to make more use of pictures/photos of meals to allow people to have more choice. The kitchen was seen to be clean but it is recommended that staff regularly check food stores as the inspector found a mouldy carrot in the vegetable rack and a tin of opened evaporated milk in the fridge. It becomes a recommendation of this inspection report that staff develop a better system that allows people to have a choice. A record of the meals and food available showed a good variety was offered. Coombe End DS0000067015.V337435.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, 20, 21 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal care needs are assessed, care plans are in place and this allows staff to meet peoples needs consistently. Peoples healthcare needs have not been assessed and this may mean peoples needs are not being met. Medication administration needs to be reviewed to ensure that people are not being put at risk. The use of the “best interest” document ensure that where a person cannot consent that their needs are met appropriately. EVIDENCE: Peoples personal care needs are detailed in their care plans. All of the personal files examined contained detailed notes from other professionals. None of the files examined contained healthcare assessments. It is a recommendation of this inspection report that this is addressed. Medication administration was examined, three shortfalls were identified: Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 16 • • Two of the “general” protocols should be moved to the front of the medication file to make them easier to find. Two of the three people have a PRN medication protocol. One person did not have a protocol although they require PRN medication. This must be addressed to minimise the risk of an unnecessary medication error. As identified earlier in this report the staff have used “best interest” documents to make decisions where it is judged a person is unable to consent. In relation to peoples medication the home have completed one of these documents for each person. Each person’s file contained a document that identified their last wishes in case of serious illness and death. Coombe End DS0000067015.V337435.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, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the home have a complaints procedure it would be difficult for people living in the home to use. Staff awareness of what they need to look for if a person is unhappy is more important and what actions they would take in that situation. EVIDENCE: The home has a complaints procedure. There have been no complaints made to the manager or the CSCI since the previous inspection was completed. Staff spoken with gave good examples of how they can support people living at the home who have communication difficulties to make a complaint. They showed a good awareness of monitoring people’s behaviour, using family members and other professionals. The inspector checked the financial records for each of the people living at the home and found no errors. Records seen were detailed and clearly provided evidence of transactions. Whilst completing the tour of the premises the inspector noted that one person’s bedroom door had a bolt lock on the outside. Staff explained that this was to stop other people living in the home from going into this person’s Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 18 bedroom and taking their possessions. The inspector understands the theory behind this but was unable to find any documentation to support the practice. The manager must ensure that a protocol is written to support this practice. This may include the use of the home’s best practice document. It is recommended that the manager also looks at different methods that could be used to lock bedroom doors. Coombe End DS0000067015.V337435.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, 25, 26, 27, 28, 29, 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment in the home is poor and does not meet the needs of the people living in the home. EVIDENCE: Coombe End is a large detached property that has been deemed by the provider as “no longer fit for purpose”. At present redevelopment is being planned, but has not been agreed. This has now created a situation where the housing provider (Advance Housing) does not feel it is appropriate to agree expenditure for a programme of decoration. This is unacceptable to the CSCI when the level of decoration is so poor, and that there is no date as to when the re-development will be completed. This may mean that people will have to live in these unacceptable conditions for a considerable period of time. Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 20 At the time of the site visit the following issues were identified: Dining room: • Worn armchairs with holes in the coverings • Curtain hanging off the pole • Floor covering ripped • Paintwork poor, example – wall lights had been removed and holes filled but not repainted. Lounge: • Smelt of urine • A mixture of worn sofas • Paintwork poor (chipped, faded, dirty) Kitchen: • Paintwork poor Main corridor: • Paintwork poor Toilet off main corridor: • Toilet seat missing • Toilet door has no lock Top of front stairs: • An amount of plaster had fallen off 2nd floor, yellow bathroom: • Sink taps not working and no plug • Cobwebs in the corners • Areas of the bathroom were unclean 2nd floor green toilet: • Border coming away from the wall • Significant number of dead insects in the light fitting. Other areas of the home were satisfactory. All of the bedrooms for the people living in the home were seen and showed that they were well decorated and personalised with personal possessions. The home has a sensory room that is used by people living there. There is an assisted bathroom and a qualified engineer had serviced the specialised equipment within the past 12 months. The home’s laundry is satisfactory and provides staff with an industrial washing machine and tumble dryer. Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. CRB disclosures must be kept in the home as specified in the regulations it is impossible to confirm that people are not being put at unnecessary risks. Staff have access to a wide range of training that enables them to meet the needs of the people living in the home. Staff are available in sufficient numbers to meet peoples needs. EVIDENCE: Staff files were examined and showed that in most cases each person’s file contained the information required by these regulations. All but one file contained a memo from head office confirming that Criminal Records Bureau (CRB) disclosures had been obtained. One person’s file did not contain any reference to a CRB disclosure. From speaking to a colleague the inspector understands that it has been agreed with us that CRBs for staff are to be kept in each of the homes. This does not appear to be happening here. It is a requirement of this inspection report that this is addressed. Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 22 Speaking with staff they commented that since the Brandon Trust have taken over the amount of training offered to staff has increased significantly. Staff spoke about attending courses in fire safety, food hygiene, manual handling and other courses considered as mandatory. Newer staff have completed the learning disability award framework (LDAF) while others are completing National Vocational Qualifications (NVQ). Brandon Trust have produced a training programme for 07/08 and this showed in excess of 60 courses available to staff. Examining the staffing rota it showed to meet the needs of the 3 people currently living in the home there are 2 staff on each of the early and late shifts. At night there are 2 waking night staff. The manager was open and transparent in saying that staff supervision sessions are not being completed as regularly as they should be, neither meeting the Brandon Trust’s policy or the National Minimum Standards (NMS). This must be addressed by the manager and becomes a requirement of this inspection report. Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has been in post for a number of years and is due to retire in July ’07 and the organisation are currently recruiting for another manager. The quality assurance system is poor and does not allow for continuous improvement in the way it has been managed to date. People are not put at risk to due to the health and safety procedures in place. EVIDENCE: Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 24 In July ’07 the current registered manager will retire. The manager has been in post for many years and comments from staff during the inspection were all positive about their approach and the support the manager has given them. Since the Brandon Trust has become the owner of the home they have introduced a quality assurance system. Registered managers are asked to review a number of key standards and set goals for improvement with timescales for them to be achieved. Examining the agreed goals for Coombe End some goals were not specific, with no date to achieve them (instead of a date for it to be achieved it said “on going”), while none of the progress towards meeting the goals had been reviewed so goals with dates were not going to be met within the agreed timescale. Speaking to the manager and deputy the need to regularly review agreed goals was discussed. The inspector believes that the current process is not a quality assurance system and must be reviewed for it to become effective in the home. This becomes a requirement of this inspection report. The provider is completing regulation 26 visits. Examination of records relating to health and safety revealed the following: Portable appliance testing has been completed in the previous 12 months. A fire risk assessment has been completed and the deputy manager explained that this is under review at present. COSHH data sheets were available for the selection of cleaning chemicals used in the home. Fridge and freezer temperatures are monitored twice daily. A food probe is used regularly. Fire safety equipment records were examined. An appropriately qualified engineer had tested all of the equipment at regular intervals. Staff check equipment regularly and records provided evidence of this. Records of fire drills showed that the home needed to complete one. When examining the fire test log it was noted that it made reference to the 1984 Registered Care Homes Act, this has been superseded by the Care Standards 2000 Act and this was brought to the attention of the staff. It is a requirement of this inspection report that the fire safety log is updated to reflect the appropriate legislation and that staff complete a fire drill. The previous inspection report made a requirement that the manager supply the CSCI with a copy of the report into the asbestos found in the building. A copy of this report was seen at this inspection and confirmed that this issue had been addressed. Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 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 2 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 2 28 2 29 3 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 2 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 2 2 3 3 X 2 X X 3 X Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA9 Regulation 13 (4) b, c Requirement Risk assessments for people living in the home must be reviewed to ensure that they provide sufficient detail to minimise potential risks. A health assessment must be completed for each person. Medication protocols must be more organised to ensure that people are not put at any unnecessary risks. Timescale for action 10/08/07 2. 3. YA19 YA20 12, 13(1), 14 13(2) 10/08/07 20/07/07 4. YA23 13(4), (6) 5. YA24 23(2) d A medication protocol must be written for a person as identified in the body of the report. A protocol must be written to 20/07/07 support the practice of locking a person’s bedroom door from the outside. Alternative locks must be identified. There are a significant number of 28/09/07 shortfalls in this area that are listed in the body of the report. Each of these areas must be addressed: - Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 27 Dining room: - Worn armchairs with holes in the coverings • Curtain hanging off the pole • Floor covering ripped • Paintwork poor, example – wall lights had been removed and holes filled but not repainted. Lounge: • Smelt of urine • A mixture of worn sofas • Paintwork poor (chipped, faded, dirty) Kitchen: • Paintwork poor Main corridor: • Paintwork poor Top of front stairs: • An amount of plaster had fallen off The following areas were seen as poor and must be addressed: Toilet off main corridor: • Toilet seat missing • Toilet door has no lock 2nd floor, yellow bathroom: • Sink taps not working and no plug • Cobwebs in the corners • Areas of the bathroom were unclean 2nd floor green toilet: • Border coming away from the fall • Significant number of dead insects in the light fitting. The lounge smelt of urine and 20/07/07 other areas of the home were DS0000067015.V337435.R01.S.doc Version 5.2 Page 28 6. YA27 23(2) d 28/09/07 7. YA30 23(2) d, 13(3), Coombe End 16(2) k 8. YA34 7, 9, 19 Schedule 2 9. 10. YA36 YA39 18(2) 24 dirty and this must be addressed. All of the staff records must 10/08/07 either contain a CRB disclosure or confirmation from the organisation’s personnel department that one has been received and is stored securely. All staff must receive regular 10/08/07 supervision. The home must have an effective 07/09/07 quality assurance system that enables review of practices and continuous improvement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA6 YA6 YA13 YA17 YA17 Good Practice Recommendations The system of reviewing peoples care plans and other documents should be re-assessed. People’s files contained documents that had been written a number of years ago and these should be reviewed to ensure that they are still relevant. Staff should ensure that daily notes are accurate and that gaps are not left in the area to record the activities completed. Staff should check the food stores regularly to ensure that food is fit for human consumption. A system that allows people living in the home to have more choice about the food they eat must be developed. Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Coombe End DS0000067015.V337435.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!