Inspection on 18/07/07 for Cossins House Care Home

This inspection was carried out on 18th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Cossins House Care Home 31/07/08

Cossins House Care Home 20/11/06

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

CARE HOMES FOR OLDER PEOPLE Cossins House Care Home Cossins House Care Home 1 Downside Road Downside Cobham Surrey KT11 3LZ Lead Inspector Joseph Croft Unannounced Inspection 09:30 18th July 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cossins House Care Home DS0000068393.V345777.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cossins House Care Home Address Cossins House Care Home 1 Downside Road Downside Cobham Surrey KT11 3LZ 01932 862038 01932 863497 cossins.house@fshc.co.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) Grandcross Limited(wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Carol Patricia Kirby Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th November 2006 Brief Description of the Service: Cossins House is registered to provide residential care for up to 24 service users within the category of older people. Many of the service users are able to care for themselves with only minimal assistance. Accommodation for service users consists of 18 single bedrooms, with an additional three double bedrooms being provided in bungalows situated in the grounds for service users who are more independent. All bedrooms are ample in size and all but one bedroom have en-suite facilities. Access to the first floor is via a passenger lift. The communal areas are spacious and most rooms provide pleasant views of the gardens and surrounding area. The home is situated in the village of Cobham, which provides good transport links, shopping facilities and a local church. Car parking is provided at the front and side of the home. The weekly fees range from £680 to £780. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 18th July 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Regulation inspector, Mr Joe Croft, undertook this visit and the registered manager assisted him throughout. This site visit took place over a period of eight hours, commencing at 10:00 and concluding at 18:20. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The inspector had discussions with two members of staff on duty and nine residents. Discussions took place with three relatives who were visiting on the day of the site visit. Residents informed the inspector that they were very happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. The visiting relatives also stated this. Residents informed the inspector that the food was good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the home has been used as a source of evidence in this report. At the time of writing this report the Commission For Social Care Inspection had not received completed survey cards from residents, their relatives or other associated professionals. The inspector would like to thank the manager, members of staff and residents for their co-operation during this visit. Feedback was provided to the manager at the end of this site visit. What the service does well: Assessment documentation is in place to ensure that the individual needs of residents can be met. Residents’ lifestyles matched their needs and preferences and, where possible, they are able to maintain contact with family, friends and the local community. Residents are offered a balanced diet and choice of meals. People using the service are provided with good communal and individual living space, making it a safe and comfortable place to live. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 6 Residents and relatives were very complimentary about the care that is delivered by staff working at the home. Residents spoken to stated they were very happy living at the home, and that they are able to make choices and have their own belongings in their bedrooms. Residents’ views are continually sought, to improve the service the home provides. 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. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were assessed. 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. Assessment documentation is in place to ensure that the individual needs of residents can be met. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) completed by the manager indicates that the home undertakes pre-admission assessments. The home has an admissions policy in place. Three care files were sampled as part of the case tracking process. Each file contained pre–admission assessments that included information in regard to health, personal care, daily life skills, nutrition and emotional and social needs. It was observed that equality and diversity needs were recorded. Care plans are developed from these assessments. The manager informed the inspector that a copy of the community care assessment is obtained for residents who are funded. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 9 The manager and staff informed the inspector that residents are encouraged to visit the home with their relatives. This was confirmed during discussions with residents and relatives who were present during the site visit. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA) that was submitted to the Commission For Social Care Inspection by the manager. The home does not offer intermediate care. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has care plans and risk assessments in place. However, identified shortfalls must be addressed to ensure that the changing needs of residents are being met. Personal and health care is offered in such a way as to promote residents’ privacy and dignity. EVIDENCE: Three care files were sampled and each had individual care plans that had been signed and dated by residents and/or their relatives. Care plans included information in regard to their health, personal and social care needs, and risk assessments that included falls, nutrition and Waterlow scores. Cultural and religious needs were recorded. It was observed that two of the care plans sampled were last reviewed in May 2007. The manager informed the inspector that this was because staff are currently in the process of changing the care plans to Person-Centred Plans. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 11 It was noted that one care plan did not include up to date information in regard to one resident who has diabetes. The care plan informed that staff are to monitor the blood sugar levels for this particular resident twice a week. However, the manager informed the inspector this was not the case. An immediate requirement has been made that this care plan must be fully reviewed to ensure that the changing needs of the identified resident are being met. It was also noted that the bedroom for the same resident, who has a visual impairment and is registered blind, is situated on the first floor of the care home, with two further steps to climb to access their bedroom. An immediate requirement was made that a detailed risk assessment must be written to ensure that the health, safety and welfare of this resident is maintained at all times. The manager attended to these requirements within 24 hours and submitted the action taken to ensure that the health, safety and welfare of the resident is maintained. The district nurse now visits the home to conduct the blood tests, and the GP has been consulted. During discussions staff were able to give an account of the care plans, and were aware that they must be reviewed on a monthly basis. Residents and relatives spoken to during the site visit stated that they were aware of the care plans, and had signed them. Evidence was seen that residents have access to all national health care services. During discussions residents informed the inspector that they can visit the GP at the surgery, or the GP will see them in the privacy of their bedrooms. Residents stated that they always receive their medication on time. The Annual Quality Assurance Assessment (AQAA) completed by the manager informed that the home has a policy and procedure in regard to the administration of medicines. This had been reviewed in March 2006. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. The MAR sheets sampled were found to be in good order with no omissions in signatures. Medication was stored in a secure metal medicine cabinet. Residents who wish to self medicate had risk assessments in place. The manager informed the inspector that only staff who have received the appropriate training administer the medication. This was confirmed during discussions with staff and the viewing of training records. Residents informed the inspector that they are treated with dignity and respect. Residents spoken to all had their own landline telephones in their bedrooms. Staff informed the inspector that they respect residents’ privacy through attending to personal care needs in private, knocking on bedroom doors and addressing residents by the names they preferred. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 12 The home uses the organisation’s Equality and Diversity Policy and Procedure that was last reviewed in March 2006. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyles matched their needs and preferences and, where possible, they are able to maintain contact with family, friends and the local community. People who use the service are offered a balanced diet. EVIDENCE: Activities are being provided at the home. The manager informed the inspector that they have recently recruited an activity organiser who will work in the afternoons from Monday to Friday. This person will commence their duties when the Criminal Records Bureau check and references have been received. The home currently employs one activity organiser who works at the home once every two weeks. Activities currently offered include board games, reminiscence, knitting and keep fit exercises. During discussions residents informed the inspector that activities are organised by the home, but they do not always wish to take part in them. There is a pianist who visits the home every four weeks, and the home has a minibus that is regularly used to take residents on trips outside of the home. Each resident has a list of the weekly activities in their bedrooms. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 14 The majority of residents living at the home are white British; five residents are of South African origin. Residents informed the inspector that their religious and cultural needs are respected. One resident stated that she attends Church services every week, others stated that a church leader visits every Sunday. Residents and relatives informed the inspector there are no restrictions on visiting the home. The manager stated that all but one resident has family contact. The resident who has no family contact has advocates visiting. Residents stated they make everyday choices about their lives. Residents stated that they like their bedrooms and the staff, who are always available to help them when required. The home has a cook who has produced a menu that offers a choice of meals. The home consulted with a dietician from the local Primary Care Trust in December 2006, who offered advice on the future of planning the menus. The manager informed the inspector that they are using Client Satisfaction Monitoring forms for residents to complete in regard to the food they receive. During discussions, residents stated that they found the food to be very good. However, one resident informed the inspector that the food was usually good. The cook visits them each morning to ask what they would like for lunch. Lunch was observed during this site visit. Residents were eating in a relaxed atmosphere with appropriate numbers of staff available to offer assistance as and when required. Records of alternative meals taken by residents are maintained by the home. The cook has a list of each resident’s breakfast preferences. Menus were viewed, and they included meat, fish, pasta, fresh vegetables and fruit. The menus viewed did not include the choices for breakfast or the evening meal. A good practice recommendation has been made that these should be included on the menu. Residents were observed having drinks throughout the site visit. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Staff require refresher training in the protection of vulnerable adults to ensure that residents are protected from abuse. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the home. The home follows the organisation’s Complaints Policy and Procedure that was last reviewed in March 2006. This document includes the timescales for responding to complainants and contact details for the Commission For Social Care Inspection. The manager informed the inspector that the organisation is currently dealing with a recent complaint. The manager has a folder where complaints received are maintained; however, a good practice recommendation has been made that the manager maintains a record of how complaints are resolved. During discussions, residents stated that they have a copy of the Complaints Procedure in their Service Users Guide. Residents stated that they would talk to the manager if they had any complaints to make. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 16 The home follows the organisation’s policy and procedure in regard to the protection of vulnerable adults, and has a copy of the recent Surrey Multi–Agency Procedures. The manager has attended the Surrey Multi-Agency training in regard to the protection of vulnerable adults in March 2005, and had last cascaded this training to staff in October 2005. A requirement has been made that staff must receive annual refresher training in regard to the protection of vulnerable adults to ensure that residents are protected from abuse. The manager informed the inspector that refresher training for all staff will be attended to immediately. During discussions staff informed the inspector they would report all concerns to the manager, and would not hesitate to follow the organisation’s procedure with regard to whistle blowing. The manager informed the inspector that the home does not have any dealings with regard to residents’ finances. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with good communal and individual living space, making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. Accommodation is situated on two floors. Accommodation for residents consists of 18 single bedrooms, with an additional three double bedrooms being provided in bungalows situated in the grounds for residents who are more independent. Bedrooms visited were ample in size and all but one bedroom have en-suite facilities. Access to the first floor is via a passenger lift. Residents’ bedrooms sampled were appropriately decorated and contained their personal possessions and family photographs. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 18 Residents stated that they like their bedrooms and having their own belongings with them. Bedrooms viewed had call bells within easy reach of residents. All communal areas are accessible to residents. The home has grab rails that help residents to maintain their independence. Bathrooms and toilets had paper towels and liquid soap. It was noted that the blind in bathroom 12 had come down, and the flooring requires attention. The manager informed the inspector that this would be addressed, and that plans are in place to redecorate the hallway between the office and the kitchen. Requirements made during the last site visit have been complied with. On the day of this site visit the home was found to be clean, tidy and free from offensive odours. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the needs of residents. The home has a recruitment policy and procedure in place; however, this has not always been followed when recruiting staff, therefore not fully protecting the residents. Attention is required in regard to training for staff. EVIDENCE: The manager informed the inspector that there are three members of staff on each shift, with the manager as supernumerary, two waking night staff, one cook and one domestic. The home is currently in the process of recruiting a deputy manager, one senior carer and one domestic. The duty rota was viewed. However, it was difficult to ascertain the exact hours being worked as staff had made handwritten changes to the rota. A requirement has been made that an accurate copy of the duty rota detailing the hours of all persons actually working at the home must be maintained to ensure that residents needs are being met by sufficient numbers and skill mix of staff. Eleven staff are currently employed at the care home, six of whom hold the minimum NVQ Level 2 and/or equivalent, therefore the care home meets the Nation Minimum Standard in regard to 50 of staff holding the NVQ Level 2 and above. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 20 The home follows the organisation’s recruitment policy and procedure. Two staff recruitment files were sampled during this site visit. These included application forms, two written references, and Criminal Record Bureau and POVA first checks. However, there were no records for gaps in employment, no reasons for leaving previous employment that included working with vulnerable people, and no recent photographs of staff. A requirement has been made that staff recruitment files must include all as stated in Schedule 2 of the Care Homes Regulations 2001. The manager informed the inspector that staff are receiving induction training, and the home has registered the staff with the Skills for Care Council. Staff training files provided evidence of training undertaken. However, it was noted that training in regard to the ageing needs of residents, diabetes or visual impairment had not been provided for staff. A requirement has been made that staff must receive training appropriate to the work they are to perform to ensure that the changing needs of older people can be met. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, issues in regard to care plans, risk assessments, staff recruitment and training must be addressed to ensure that the safety and welfare of the residents is maintained. EVIDENCE: The registered manager informed the inspector that she has thirty years experience of working with older people, has completed the NVQ Level 4 and the Registered Managers Award (RMA) and has attended training in regard to dementia, fire and the Surrey Multi–Agency Protection of Vulnerable Adults. The manager must address the issues raised in this report in regard to care plans, risk assessments, staff recruitment and staff training. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 22 The manager informed the inspector that quality assurance is undertaken by the organisation through annual surveys for residents, their relatives and other associated professionals. The next survey is due in October/November 2007. Regulation 26 visits had been undertaken, but the last report held at the home was dated January 2007. The manager stated that she would request copies of the missing reports. Residents’ meetings are taking place; however, the last one was held in February 2007. The manager informed the inspector that these would be undertaken on a two-monthly-basis. The manager informed the inspector that residents’ and/or their relatives manage their finances, and the home does not get involved with the residents’ finances. Staff supervision is not being undertaken on a regular basis, and it was noted that one staff member had not yet received formal one-to-one supervision. A requirement in regard to this has been made. Sampling of staff training records provided evidence that staff are receiving the mandatory training as required. Information provided in the AQAA informs that annual health and safety checks are undertaken. The home follows the organisation’s Health and Safety Policy and Procedure. During the site visit a sample of health and safety checks undertaken were viewed. These included the gas certificate on 5/6/06, electrical installation on 11/6/07, fire detection and fighting equipment on 4/5/07, portable appliance testing on 23/5/07 and the Employers Liability Insurance that expires on 30/6/08. Staff spoken to were complimentary about the manager. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement The identified care plan must be fully reviewed to ensure that the changing needs of the identified resident are being met. A detailed risk assessment must be written in regard to the use of a bedroom for an identified resident who has a visual impairment. This will ensure that the health, safety and welfare of the resident is maintained at all times. Staff must receive annual refresher training in regard to the protection of vulnerable adults to ensure that residents are protected from abuse. An accurate copy of the duty rota detailing the hours of all persons actually working at the home must be maintained. Staff recruitment files must include all information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001. Timescale for action 18/07/07 2. OP7 13(4) (c) 18/07/07 3. OP18 13 (6) 18/08/07 4. OP27 18 (1) (a) 18/08/07 5. OP29 19(1)(b) Schedule2 18/08/07 Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 25 6. OP30 18 (1) (c) 7. OP36 18 (2) Staff must receive training appropriate to the work they are to perform to ensure that the changing needs of older people can be met. Staff must receive the minimum of six formal supervisions per year to ensure that all aspects of care practices and career development are discussed and monitored. 18/09/07 18/08/07 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. 2. Refer to Standard OP15 OP16 Good Practice Recommendations The menus should include the choices offered for breakfast or the evening meal. It is recommended that the manager maintain a record of how complaints are resolved. Cossins House Care Home DS0000068393.V345777.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Cossins House Care Home DS0000068393.V345777.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. 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