Inspection on 16/05/06 for Cossham Gardens

This inspection was carried out on 16th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cossham Gardens 05/02/08

Cossham Gardens 21/10/05

Cossham Gardens 20/05/05

Cossham Gardens 12/11/04

Cossham Gardens 17/05/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Cossham Gardens Lodge Road Kingswood South Glos BS15 1LE Lead Inspector Andrew Pollard Unannounced Inspection 16th May 2006 09:30 Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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 Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cossham Gardens Address Lodge Road Kingswood South Glos BS15 1LE 0117 9673667 0117 9670849 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.leonard-cheshire.org.uk Leonard Cheshire Juliette Nicola Millard Care Home 16 Category(ies) of Physical disability (16) registration, with number of places Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing Notice dated 29/03/2000 applies Manager must be a RN on parts 1 or 12 of the NMC register May accommodate persons aged 19 years and over only. Date of last inspection 21st October 2005 Brief Description of the Service: Cossham Gardens is registered as a Care Home with nursing for a maximum of 16 residents with profound disability, all of who require nursing care. The Home is situated in Kingswood, behind Cossham Hospital and is set in its own grounds. The home is a purpose built property providing accommodation in 16 single en-suite rooms designed for people with physical disabilities. There is communal and activity space in 5 areas. It has easy access to local community facilities and is less than 1 mile from local shops and services and 4 miles to Bristol city centre. It can be accessed by car, or by bus with a short walk. There are pleasant gardens to the rear and side of the property. All parts of the home are accessible to wheelchair users as well as the able-bodied. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering have been used in the production of this report; pre-inspection questionnaire observation, discussion with residents, staff and relatives, a tour of the home and sampling policies, records and care plans. Three comment cards were returned. Judgements in this report have been made using all available evidence including a visit to the home. The house was purpose built for disabled people and is generally well designed for the function. It is well furnished and equipped to a high standard. The house is considered a home for life and all physical health care needs would be met including end of life care. The home is an open, well-managed and friendly establishment and has a pleasant relaxed atmosphere. There are a small number of recommendations set out in this report, which were discussed during the inspection but the standards overall are high. The inspector was only able to verbally communicate with one resident and spoke with a relative and several members of staff. Residents appeared content and well cared for. The one resident and relative spoken with gave praise for the staff and their caring attitude. The fees at the date of inspection were £1,100 per week for block-contracted beds. Other rates ranged from £1,200 to £1,800 per week. What the service does well: Care is individualised and where appropriate the multidisciplinary approach is used to maintain, enhance and develop independence and skills. Residents are treated as individuals and with respect. A high standard of care is provided to people with complex and continuing needs in a professional caring and friendly manner. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 6 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. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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 Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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): 1, 2, 5 The overall quality of this outcome area is good. Prospective residents or their families have all relevant information to decide it the home can meet their needs. A thorough assessment of prospective residents needs is carried out. Trial visits give prospective residents an opportunity to assess the nature of the home where practical. All residents have term and conditions of residence. EVIDENCE: The certificate was in order and on display in the foyer The Statement of Purpose (SOP), Service User Guide (SUG) and inspection report are available in the foyer. Residents have been issued with an individual copy of the service user guide. There have been minor revisions and updates of these documents, which are clearly written and provide all the information a prospective resident or purchaser require. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 9 There are 8 residents and 2 respite care beds funded by and under the care of the local PCT. The remainder are placed by Social Services. Detail of fees is noted in the summary. Some activities, holidays, hairdressing and toiletries are charged as extra. A number of residents pay for private chiropody and other therapists to visit. There has been one new admission since the last inspection. A full preadmission assessment was completed including a visit to the person in hospital. Both Health and Local Authorities supply assessment materials prior to any admission. The manager or other senior first level nursing staff carries out assessments, using a comprehensive and holistic pre admission assessment documents. The documents were completed and along with other materials provide the basis for the initial care plan. Room choice is generally limited to that where a vacancy arises, however the rooms are similar in layout and size. Potential residents are invited to visit the home where possible and are invited for a meal and to meet other residents leading to an overnight stay where practical. Viewings are normally undertaken in the company of a relative or social worker to assess if needs can be met and if the home is suitable for the prospective resident if they wish to move in. A formal three-month trial is followed by a full review. No emergency admissions are accepted. The outcomes of the NHS and Social Services care reviews and care plan evaluations demonstrate the home’s ability to meet needs. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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, 8, 9 The overall quality of this outcome area is good. The care plans identify needs and give clear directions to staff. Evaluation and review of care takes place. Residents or their advocates are consulted with about care matters and decisions about the way the home operates. Risk assessments are clear and detailed. Confidentiality of information is maintained well. EVIDENCE: The model of care is based on the activities of daily living and social model of disability. A named Registered Nurse and key workers are responsible for planning and reviewing care in consultation with residents or their representative. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 11 Where possible residents or relatives have engaged with this process and sign acceptance of care plans. Consent is sought for any restrictions of liberty and to allow staff to discuss service provision with other professionals. Residents can indicate gender preferences of staff giving personal care. Care planning documentation; evaluations and review of care plans were detailed and up to date. The overall standard of documentation remains good. Each person has individualised risk assessments in case files. Waterlow and Sterling index assessments and risk assessments for moving and handling, falls and nutritional risk are carried out and regularly reviewed. The home’s Physiotherapist writes additional assessments and care plans with clear directions for staff to follow. Care staff write a record of personal care and a daily diary entry. Full records of other medical and Para-medical interventions are included in the case file. The nature of many of the resident’s disabilities means that meaningful participation in the running of the home is limited by their ability to communicate; therefore relationship building with staff is vital. The involvement of residents in decision-making relies heavily on these relationships and non-verbal communication or recognition of behaviours. Many relatives take an advocacy role on behalf of residents. Formal advocacy services can be accessed if needed. The organisation has Data Protection registration although no copy of the certificate was seen. The home has a confidentiality policy. Case files and records are stored securely. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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, 17 The overall quality of this outcome area is good. The staff strive to enhance the quality of life for the residents by arranging recreational and social activities but the outcomes for residents in terms of participation in these activities is not recorded. The budget for activities is inadequate. Residents’ families are involved and informed of issues related to their relatives. The menus are varied and offer individual choice and a healthy diet. Appropriate arrangements are in place to support residents with peg feeds. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 13 EVIDENCE: An activities organiser works 35 hours per week. There are in addition two carers who are engaged with activities for 23 hours a week jointly. At present there is one volunteer who works in the gardens Activities are targeted to individuals and require mostly one to one work. Some group activities are undertaken such as craftwork, cooking and trips out. The views of staff was that the budget of £20 a week for all the residents was inadequate to provide the level of recreational and social activities they felt the residents wished for. The Inspector concurs with this view. It was unclear what the true level of activities is as there are very minimal records of what takes place. The manager is to introduce daily diary entries to record such. A number of residents will be taken on holiday by staff to adapted facilities in chalets or caravans. The issue was raised by staff about the lack of an adjustable bed in one of the properties previously used, the manager is to check that this has been resolved before the next group goes away. The home has a well equipped activities and multi-sensory room. Many residents enjoy a foot or hand massage from the aroma therapist. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 14 The majority of residents have strong family ties and their relatives are actively involved with the home. The residents’ forum has been reinstated and is chaired by the service users support group facilitator who works with a small group of residents and some one to one work. Records of meetings are made and indicate participation and consultation with residents is taking place. A local clergyman arranges services and attends to residents spiritual needs as required. There was a Harvest festival service and also carol concerts at Christmas. The home also has some links with the local Salvation Army. There are no residents from other than Christian faith backgrounds at present or any one with special cultural needs. The cook has previously carried out surveys of resident likes and dislikes and plans a weekly menu. Each person has an eating plan addressing their individual requirements and equipment to assist them. Daily choices of food are offered at each meal and alternatives are always available. The menu was varied and offered a balanced diet. Three people are able to feed themselves, the majority needing to be fed. Eight residents have peg feeds. A dietician supports the staff and provides advice. All residents have their own feed programmes. The home has previously won a good food commendation from the EHO. The cook has completed the appropriate qualifications to teach basic food hygiene to the staff. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 The overall quality of this outcome area is good. There are good arrangements in place to provide personal and health care to the residents. Proper and safe procedures are in place to manage store and administer medication. EVIDENCE: The PCT or continuing care funding funds a number of resident’s placements. All residents require nursing care in addition to personal/social care. The house is considered a home for life and all physical health care needs can be met including end of life care. The manager has training and experience in managing terminal care. The staff have gained wide experience in managing care needs for the residents and family at the end of life. The doctors at the neighbouring Lodgeside practice provide primary care services on rotation. A doctor visits the home every Tuesday or Thursday or as required. Where practical some residents will be escorted to the surgery for Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 16 appointments. The manager considers the home is well supported by the local practice that provides a high quality of service to the residents. Respite care residents can be registered as temporary residents during their stay. All bar one of the residents require staff support to access primary or secondary care services. A number of residents are under the care of consultant Neurologists or consultants in Rehabilitation. A physiotherapist is employed 19 hours per week. Chiropody, speech therapy, dental and OT services are accessed when needed and in general domiciliary appointments are made. Some residents also employ private physiotherapists and aroma therapists. The manager has previously has clarified lines of accountability and insurance arrangements for these staff all of whom have had CRB checks. A medication policy, procedure and risk assessment systems are in place. Registered Nurses have responsibility for the management of medication. None of the residents are able to self medicate. However one resident did express a desire to explore this possibility and is likely to do this as part of an upcoming move to a flat at Greenhill House. The home has recently changed its medication system to a monitored dose system, which is working well and has resolved stock control problems. The supplying pharmacist carries out monitoring and staff training periodically. The receipt and administration records were in order. There are no Controlled Drugs in use at present. Proper arrangements have been made for the recording and disposal of unwanted medication. Temperature recordings for the drugs fridge are monitored and recorded daily. There are two suction machines, one of which is portable. There are ridged catheters available for these machines. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The overall quality of this outcome area is good. The complaint and POVA policies are clear and detailed. The staff are aware of the complaints and POVA policies and are trained in putting them into practice to protect residents from abuse. The record keeping related to petty cash and residents’ money held in safekeeping is satisfactory. EVIDENCE: The complaint procedure is a comprehensive document. The policy makes reference to CSCI as is required. There are alternative simplified and tape formats available for resident use if needed. A detailed log of complaints and their outcomes is kept and full details of complaints, actions and outcomes are recorded. There has been one complaint from a resident since the last inspection concerning personal care at night. An external manager from the organisation who found the complaint substantiated investigated the issue. As a result discussions with the night staff and resident found a way to proceed to the residents satisfaction and the matter was fully resolved. In talking to the resident during the inspection they said “I can’t praise the staff highly enough they are very professional and caring.” There is a policy for the management, storage and record keeping of resident’s monies and valuables. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 18 The manager and administrator are the only key holders for the safe and do not work at weekends so a small cash float is available to staff at weekends for which records and receipts are kept. All residents have a small safe in their rooms and each person has a record book of credits, debits and balances. One resident is able to manage their own money the remainder require staff or relatives to assist. The home has written procedures for adult protection, whistle blowing, management of aggression, abuse and bullying. The home’s Protection of Vulnerable Adults (POVA) statement gives a clear process to be followed. The DOH ‘No Secrets’ document and the Local Authority version of the same was available. All staff have completed POVA update training and it is part of staff induction programmes. The manager has recently completed a trainer’s course in POVA issues and provides staff updates and training in other homes. There have been no allegations of abuse. All staff have been issued with the GSCC code of practice. The staff spoken with considered that the residents were treated with respect and dignity by all staff in the home. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 The overall quality of this outcome area is good. The house is a clean, comfortable and safe environment for the current residents. The bedrooms and communal rooms and facilities are suitable for their purpose and meet the residents’ needs. Residents have any specialist equipment they presently require to maintain and promote their independence. EVIDENCE: The house was purpose built for disabled people and is generally well designed for the function. It is furnished to a high standard. The standard of décor is good and since the appointment of a handyman routine household maintenance is well managed. The home is suitably equipped to meet the resident care needs and has sufficient fixed and mobile hoists. All bedrooms are single en-suites and have a Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 20 ceiling tracking system to aid resident mobility and safeguard staff. The bedrooms are well equipped with pressure relieving equipment and specialist beds. All residents have their own chairs and wheelchairs. Some residents have an electronic door opening system and others can be fitted if residents are able to use them. Bedrooms evidence a great degree of personalisation. All bathrooms and WC’s are large and suitable for disabled use and have a range of specialist baths and showers. It was agreed that one bathroom can be taken out of commission and will be converted into much needed storage space. All residents require staff support to use toilet and bathroom facilities. Two of the four separate communal areas are currently used as part dining rooms. There is one activity room, a Physiotherapy room and a sensory/multimedia room. The home was clean, tidy and in good order. The laundry facilities are good. The kitchen was clean and in good order. The food hazard analysis has been updated. Detailed cleaning and temperature records are maintained. Due to recent break-ins and nuisance behaviour by youths in the grounds an improved CCTV system is to be installed and some windows have internal grills fitted. There have been no serious incidents lately. Residents reported in a recent survey that they felt safe and secure in the home. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 The overall quality of this outcome area is good. The recruitment and checking process is well organised and robust and this helps to safeguard residents. The staff are experienced and trained to meet the individual and joint needs of the residents. The staff skill mix and staffing levels are conducive to maintaining the residents quality of life. The home has a clear commitment to and focuses on training. EVIDENCE: Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 22 The staff rota shows at least eight care staff and one Registered Nurse (RN) works each morning, four plus one in the afternoon and two plus one (waking) staff at night. The manager is supernumerary. Other RN’s are also given supernumerary time for managing care records and personal development. These staffing levels are above the minimum levels set in the staffing notice but reflect the high dependency levels of the residents. Staff spoken to considered the staffing to be sufficient to meet resident’s needs. One bank RN and three carers have recently been recruited which has reduced the demand for agency staff. All agency staff have orientation and induction into the home and consistency of staff used is maintained. There are various therapists, activities staff and at times volunteers working at the home. There is a full and part time cook. There is 28 hours domestic staff and 20 hours laundry staff each week. A maintenance man works 21 hours per week. Training staff and admin staff are also employed. A new post of resident communication assistant and volunteer co-ordinator has been created. Files for recently employed staff evidenced a robust recruitment process and contained all the required documentation. The process for carrying out CRB and POVA checks for staff is carried out by the organisation’s head office, which supplies a list of satisfactory checks received. It was unclear what policy the organisation has for renewals of CRB’s. RN validations with the Nursing & Midwifery Council had been completed and were up to date. All new staff completes a detailed orientation and induction programme. The training co-ordinator has completed a training matrix and identified an annual training plan for each person to ensure all staff attends required training. First aid training was taking place on the day of the site visit. The identification of learning needs is addressed through the appraisal and supervision process. However although the supervision arrangements are working the appraisal system is not properly established and some staff required training to use it. Detailed training records for RN’s clinical updating and care staff training are maintained. The staff spoken to felt the organisation offered good access to training and felt the issue had high priority in the home. Twelve carers have NVQ level 2 and three level 3, a further eleven are on Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 23 programmes. There are three NVQ assessors at the home. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 The overall quality of this outcome area is good. The staff are motivated to maintain and improve the residents quality of life. The staff seek to empower the residents and safeguard them from hazards. The home is a safe and well-maintained home. EVIDENCE: Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 25 The organisation has a clear management structure and the home is well supported by the organisation. The manager is well qualified and has a thorough understanding of her role and responsibilities. The staff, residents and a visitor spoken with were very complimentary about Ms Millard. The organisation has a quality monitoring system linked to perfomance indicators A service review was recently conducted and a formal review indicated good progress has been made on implimenting the action plan. A resident survey was conducted in December but it was not very suitable for the home’s resident group. Only 7 people took part so the results which were written up in percentages could be misleading. The manager and staff are in the process of carrying out an organisation self audit which will generate an action plan in due course. All residents have contract reviews carried out by Social services, the NHS and multi disciplinary reviews which indicates a good quality of care. The home has retained it MS society preferred provider status. The organisation has Health and Safety policies and procedures and employs a Health and Safety Advisor. One of the staff has delegated responsibility for health and safety within the home. There is a monthly H&S audit carried out and a quarterly H&S committee meets at the home. The boilers and hoist/bath equipment has been serviced. The fire log details were up to date and in order, training and drills have taken place. A maintenance man works three days per week and the home is in good order. Hot water temperatures are monitored regularly. There is a system in place to manage the risk of legionella. PAT testing is regularly carried out. All staff receive mandatory training in load handling, first aid, fire safety, food hygiene and health and safety. The home has trained first aiders. Food hygiene training for staff is to be provided by the cook. Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 3 X 3 X X 3 3 Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 27 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. Standard Regulation Requirement Timescale for action 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 YA14 Good Practice Recommendations Keep a more detailed record of resident’s participation with social and recreational activities. Increase the activities budget from the current £20 a month for sixteen residents. Determine a policy on renewals of CRB checks. Ensure that all support staff receive an annual appraisal and the staff who carry such appraisals out are properly prepared for the role. Devise a more relevant resident survey tool that can more accurately reflect the views of people with profound disability. 2. 3. 4 YA34 YA35 YA43 Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cossham Gardens DS0000020230.V293183.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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