Inspection on 21/02/07 for Coombe House

This inspection was carried out on 21st February 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Coombe House 54 Broomfield Road Kidderminster Worcestershire DY11 5PH Lead Inspector Dianne Thompson Unannounced Inspection 21 February 2007 11:00 st Coombe House DS0000066929.V326039.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 House DS0000066929.V326039.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 House DS0000066929.V326039.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe House Address 54 Broomfield Road Kidderminster Worcestershire DY11 5PH 01562 824770 01562 750780 info.coombehouse@praxiscaregroup.org.uk 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) Praxis Care Group Mrs Emma Louise White Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one person who has an additional dementia illness. Date of last inspection Brief Description of the Service: Coombe House provides 24 hour personal and nursing care for up to a maximum of 13 service users with a learning disability, and also in some cases, a physical disability and one person aged 65 years. A recent application for a variation to registration categories has been made to CSCI (Commission for Social Care Inspection) to reduce the number of service users to 12. The home is a period style building in a residential suburb of Kidderminster. Individual accommodation is provided on both floors of the building. There are 11 single bedrooms and 1 double bedroom. Communal facilities include 2 lounge areas and a dining room. Access to the first floor area is gained through either a central staircase or a passenger lift. The manager Emma White, has been in post since September 2004. Praxis care Group is the registered provider, and the Director of Care Irene Sloan is the Responsible Individual. Praxis Care Group became the registered provider on 1st April 2006. The current fee for the service is £1244.31 per week. Charges which are additional to the fee include: • • • • • • • Personal toiletries, clothing and electrical items (TV and music centre). Activities not covered by the allowance made by the provider or in the funding authority contract Holidays Major extra outings Hairdressing Reflexology Beauty therapy Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Coombe House. This was the home’s first inspection since Praxis Care Group registered as the care provider. The main purpose of this inspection was to assess the service provided against key National Minimum Standards. Service user and staff records were examined, and a tour of the building was also carried out. Accumulated evidence from reports of monthly visits by the provider’s representative was used to inform this report. Time was spent with the registered manager, service users and staff on duty. Surveys were sent out to relatives and medical professionals prior to the inspection visit What the service does well: Coombe House is located in a residential area of Kidderminster. The home is a large building where twelve people who have learning and physical disabilities live. The home is spacious with bathrooms, toilets and equipment to meet the needs of service users. Information is available about the services offered at the home to help people choose whether or not to live at Coombe House and if the home will meet their needs. Service users are helped and supported to lead active and interesting lives at Coombe House. They are also supported to stay in touch with their families and to develop friendships. The home offers a well-balanced diet and promotes healthy eating for the welfare of all service users. Personal and healthcare needs are written in care plans and provide information to make sure that care is provided in a way that service users like. The home has a medication policy and procedure to make sure that all medication is given and stored safely for the protection of service users and staff. The home’s complaints procedure has easy to understand information about how to complain. Staff support service users to have their say and to share any concerns they may have. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 6 Coombe House is a safe, spacious and very comfortable home. The home is kept clean, tidy and well decorated. There are enough staff at the home, and the staff are trained to help them support service users. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home is well managed with an open and positive approach. Praxis monitors the home in various ways to make sure the service continues to develop as service users want and that the home remains a safe place to live and work in. What has improved since the last inspection? 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 House DS0000066929.V326039.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 House DS0000066929.V326039.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, 4 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Detailed information is provided about the services offered at the home to help service users make an informed choice about whether they would like to live at Coombe House and whether the home will meet their needs. EVIDENCE: The home’s statement of purpose and service user guide has been amended to provide up to date information about the home to help prospective service users decide if they wish to live at Coombe House. Copies have been supplied to the Commission for Social Care Inspection (CSCI). The registered manager said that copies of the revised Statement of Purpose and Service User Guide are accessible to all, including visitors to the home. All service users receive copies of relevant information prior to moving into the home, which is offered in preferred formats, such as symbols, pictures, audio and large print. There are no vacancies at the home, but an admissions policy and procedure is in place should a vacancy arise. The home’s assessment process is very detailed and the manager and service users care records demonstrate that the home receives full information about prospective service users, their Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 9 background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from a range of sources including other relevant professionals, visits to previous homes or schools, and discussions with family members. Introductory visits and stays are arranged at the home prior to admission. During the introduction to the home prospective service users are given a copy of the statement of purpose and service user guide. Evidence was seen where the admissions policy and procedures had been followed for a recent admission to the home. Coombe House DS0000066929.V326039.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 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about service users assessed needs. They include risk assessments detailing how risks are to be reduced and independence promoted. Service users are supported to make choices and decisions in their daily lives and routines. EVIDENCE: Service user care plans are detailed and informative. The plans show monitoring of identified goals, and how these are to be facilitated and achieved. Staff have information to make sure that all care is provided in a preferred and consistent way that encourages independence. A person centred care plan (PCP) approach is being developed within the home and service users will be appropriately involved in planning and reviewing their own care. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 11 Files for three service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in service user files to make sure all staff have the necessary information to provide quality care. Each service user is allocated a key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. Plans are reviewed regularly or as any changes in need occur. Staff are fully aware of the plans and clearly use them to guide their practice. Handover meetings are held between shifts to make sure all information is shared. Families and relatives returned seven responses to the surveys. One respondent commented that ‘staff should be commended for their attention to detail and the care provided’. Surveys were sent to medical professionals involved with Coombe House. Three surveys were returned and one respondent commented that the home provides ‘amazing – first class care’. Risk assessments are completed for individual service users. Although the current format identifies risks and records actions to reduce or limit risks, the format could be developed further to provide a more detailed plan of the management of identified risks. A positive discussion with the registered manager and deputy manager took place and they agreed that work to develop the risk assessment format further would improve current practice. Coombe House DS0000066929.V326039.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. EVIDENCE: The home provides a range of activities for service users, both in-house and within the local community. All activities are organised to take into account the individual needs and preferences of all service users, seeking to ensure everyone has the opportunity to participate. Activities are recorded in individual files providing a clear record of individuals’ lifestyles. Evidence was seen of the ways in which the home responds to the diversity of needs, particularly where ethnic origin and cultural differences require Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 13 alternative support from all staff within the home. The home is actively considerate of alternative needs, which includes the use of interpreters, researching cultural differences, making sure all staff are aware of such needs and that they are fully informed. External activities include visits to the cinema, shopping, day trips to places such as Weston Super Mare, barge trips to Welshpool, and a pantomime was recently arranged. There is some difficulty in planning some activities for everyone, especially when people are too poorly. Day trips are now being organised which does not involve too much travelling for some people as an alternative option to holidays away from home. Day services are being planned from home for some people and include maintaining contact with friends from their past. Activities within the home include watching TV and video’s, listening to music, Snoezelen, involvement in daily routines, such as being present during the cleaning of bedrooms although service users may be unable to do the physical task; receiving foot spa and hand massage, gardening, pottery, and art therapy. Unplanned activities, depending on how people are on the day, may include visits to the local garden centres and places with animals for the tactile experiences. The registered manager talked about the plans for further development within the home, such as putting in a new pathway around the memorial garden. Provision of a composting bin will encourage recycling within the home and involve the service users. The home is to network with local charities and fundraise for the development of a sensory garden. Evidence was seen which demonstrates that regular contact with friends and family is supported. All survey respondents indicated that they were satisfied with the overall care. One commented that the home is ‘friendly and welcoming’. The home provides well-balanced meals and special diets for individuals where required. The home employs a cook who prepares and supplies all meals within the home. Food charts are kept in the kitchen. Information includes menus, alternative options, special diets and preferred choices. Records of all food and drinks taken are transferred into individual care plans. This includes a chart for service users requiring additional food supplements. Food offered is varied, healthy and appropriate to individual needs. Coombe House DS0000066929.V326039.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are clearly identified in care plans. The plans provide information and promote consistency of care and support for all service users in a way that takes into account their preferences. The home has a clear medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide detailed information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines. Individual mobility and handling guidelines are compiled for each service user. These guidelines provide details of positioning, details of slings to be used and the positioning of straps on the slings. This ensures that all staff are informed and work to preferred and agreed procedures. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 15 The home is innovative in its approach to meeting people’s needs. An example of this practice was seen where a transfer sheet had been specifically made to size for one service user. Care plans are regularly reviewed and updated as required or as identified needs change. The staff have developed extensive knowledge and experience of the people living in the home, which is evident in their care practice. However, where changes to care practice for an individual occur, all details must be clearly recorded and not rely on knowledge and experience. Staff are able to communicate with service users verbally and, in certain cases, with the additional use of gestures, sign language, and using objects of reference. Time was spent with service users who were at home during the inspection visit. Although communication was difficult, everyone seemed to be comfortable and well cared for in the home. Records of all physical checks are completed where service users have particular health issues such as weight and fluid intake. In this way the home is able to closely monitor and respond to changes or obtain appropriate medical input whenever necessary. Record keeping and information is very detailed and thorough. An example was seen in relation to the support for service users with Peg (percutaneous endoscopic gastrostomy) tube feeding. Information included a detailed feeding regime and instructions on procedures including those for the administration of medication via the tube. Additional instructions and information relating to the prevention of tube blockage and the action to take in the event of a blockage was also included. Service users and the home are well supported by medical services, which includes GP’s, audiologist, ophthalmologist, epilepsy consultant, Speech and Language Therapist, Duchene specialist, psychiatrist, dentist, community learning disability team, occupational health, and dietician. Arrangements are in place for preventative health services, such as dental checks and annual health screening. Staff on duty and the registered manager said that all personal care is given in private to promote dignity for all service users. The manager and deputy are very aware of the specialist services that could be needed to support service users and how to access them. Information in files includes a list of specialists who are involved in an individual’s medical care and the reason for their involvement to ensure staff are kept fully informed. My life books are being used and have been found to be particularly useful for service users relatives. The books help in their awareness of what is happening and how their relative is, particularly where terminal care is being provided. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 16 The home has a medication policy and procedure in place. Medicines are suitably and safely stored and there is appropriate storage for controlled drugs. Information is available to advise staff about prescribed medication together with any possible side effects. A medication information fact sheet is provided both in individual files and in the medication file for each service user and gives details of all current prescribed medication. Consent to treatment forms have been completed. Information is available regarding service users and their families’ wishes on death and dying, and includes information on preferred funeral arrangements. The home provides terminal care with compassion and sensitivity. Coombe House DS0000066929.V326039.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 Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. Service users are protected by easy to understand information about how to complain, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: During the inspection visit staff were observed engaging with service users in a supportive and respectful way. The home’s complaints procedure is available in widget signs and symbols for service users. The complaints log was examined and there are no records of complaints made to the home or to the CSCI since the previous inspection. Respondents to the surveys all indicated awareness of the complaints procedure, and all confirmed that no complaints had been made to the home. Relatives comments on behalf of service users indicated that ‘staff always treat service users well’, that the service users ‘have a good relationship with the staff and would always tell them if there was anything wrong’. The home has relevant policies for service users’ protection. Policies and procedures are available which advise and guide staff in protecting service users. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 18 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, 28, 29, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Coombe House provides accommodation for service users that meets their needs and offers a safe, spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: The inspection visit included a tour of the home. Coombe house is a large building with secluded grounds in a suburb of Kidderminster, and has access to local community and amenities. The home has suitable rooms and facilities, which provides a safe and comfortable home. The premises are clean and tidy. The two lounges and dining areas are comfortable and well furnished. Since the previous inspection both lounges have been decorated and have had new carpets and curtains. The annexe floor has been replaced and two bedrooms have been redecorated. A new phone system has been fitted throughout the Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 19 home. The hallway has been redecorated and has very much improved the overall appearance of the home. Specialist equipment is available as required. This includes specialist baths, overhead and manual hoists; stimulatory equipment in service users bedrooms such as lamps, projectors, mobiles, rope lights, and wind chimes. The home also has a sensory room with specialist equipment. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available and there are suitable arrangements in place for the disposal of clinical waste. All cleaning materials are stored in locked cupboards in the laundry room. Locks with an appropriate override device for the doors of all bedrooms, toilets and bathrooms have been fitted and completes the requirement of the previous inspection. Redevelopment plans are currently being considered to develop the building to provide further office and training room facilities. A maintenance networking relationship has established greater understanding of the home’s needs with the maintenance contractor and has resulted in improved timescales and responses to required work. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 20 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, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are being maintained and staff receive relevant training to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: Suitable staffing levels have been maintained although some staff vacancies have occurred since the last inspection. The manager said that the change to Praxis (the new provider) has been relatively smooth. The service users and staff have coped with the change of provider very well and have seen the transition period as a very positive experience. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 21 Recruitment has however been unsuccessful which may be due to the lack of awareness of the Praxis Care Group within the UK. The registered manager and the newly appointed regional director for Praxis, who was visiting on the day of the inspection, confirmed that networking is to be a priority to improve local awareness of the Organisation. Praxis provides regular staff training. Staff say this is very much improved and access to different courses is good. The registered manager said that the training analysis has been collated and training is to be arranged for the forthcoming year. Senior staff have received training in staff supervision and this meets the requirement of the previous inspection. Staff complete mandatory training such as health and safety, fire safety, first aid, food hygiene, moving and handling and infection control. Other training courses include communication, safe handling of medicines, and abuse. Additional training is provided by Macmillan Nurses who give talks for staff, discussing end of life support. These talks also include the option of counselling for staff independently or in an open forum. All newly employed staff complete an Induction Course. The Induction process also includes new staff being supported by senior staff to familiarise themselves with the home, service users and safety matters. A sample of staff records was examined. The manager confirmed that all prospective staff complete an appropriate application form and that required references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before their appointment is confirmed. All staff are required to work a probationary period at the home. Evidence was seen from the staff supervision overview form that all staff receive regular structured supervision from the management team. Staff meetings are held regularly and minutes are available. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is managed with an open and positive approach. Praxis monitors the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The registered manager and the deputy manager were available at the time of the inspection. The registered manager, Emma White is a registered nurse and has recently completed the Registered Managers Award NVQ level 4 and a Diploma in Professional Practice in Palliative Care Course. Management responsibilities in the home are shared with a deputy manager and four assistant home managers. They are all involved in organising dayto-day activities, health and safety promotion, staff supervision and induction. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 23 Staff confirmed the manager is approachable and supportive. In respect of management support from the provider, Praxis has Training and Human Resource Officers who are available to advise and support the home. Service manager meetings are held regularly and the manager confirmed that she and the home are being supported. The provider’s monthly visits are one of the ways that Praxis monitors the service and how the home is being run. These visits include interviews with staff and service users and also include an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of the home’s quality assurance and monitoring system and are intended to form an annual development plan for the service. This report will include service users, stakeholders and interested parties views on the service provision. Strategic Planning sessions and Quality Assurance training for the management team is scheduled for the coming week in Ireland. Praxis is also making an application for consideration for the Investors in People award. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health and safety training topics. Generic risk assessments are in place. A full fire inspection has been completed by a fire agency, and a detailed risk assessment compiled. The ground floor fire doors are being replaced due to wear and tear, age and loss of effectiveness, as advised during the fire inspection. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 24 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 4 3 X 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 4 29 3 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 4 4 X 3 X X 4 X Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 17(3) Requirement The registered person shall ensure that the records are kept up to date. Timescale for action 27/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations Risk assessments format should be developed further to provide a more detailed plan of the management of identified risks. Coombe House DS0000066929.V326039.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 House DS0000066929.V326039.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. 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