Inspection on 16/03/06 for Cotebrook

This inspection was carried out on 16th March 2006.

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

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

Other inspections for this house

Cotebrook 08/12/06

Cotebrook 09/09/05

Cotebrook 01/02/05

Cotebrook 08/09/04

Cotebrook 27/02/04

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Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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

CARE HOME ADULTS 18-65 Cotebrook Oughtrington Lane Lymm Warrington Cheshire WA13 0QY Lead Inspector Maureen Brown Unannounced Inspection 16 March 2006 08:50 th Cotebrook DS0000026994.V284647.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 Cotebrook DS0000026994.V284647.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. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cotebrook Address Oughtrington Lane Lymm Warrington Cheshire WA13 0QY 01925 752583 01925 753169 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) Cotebrook Homes Limited Mrs Sidney Timms Care Home 30 Category(ies) of Physical disability (30), Physical disability over registration, with number 65 years of age (10) of places Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 30 service users to include:* Up to 30 service users in the category PD (Physical disability) * Up to 10 service users in the category PD(E) (Physical disability over 65 years of age) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance that may be issued through the Commission for Social Care Inspection 9th September 2005 2. 3. Date of last inspection Brief Description of the Service: Cotebrook is a care home owned and managed by a voluntary committee. The home is located in a residential suburb of the village of Lymm, this provides good local shopping and transport links with nearby Warrington. The home has a day care facility within the grounds. The original building is a three-storey house and attached to this is a large ground floor extension. Residents are accommodated on the ground floor. The first and second floors are used for office accommodation and storage. Residents’ accommodation consists of 30 single bedrooms, two of which are used for respite care. There are a variety of communal facilities that include three lounges, two dining rooms and a conservatory. The home has extensive well-kept grounds for the use of the residents. Residents confirmed they used the garden in the better weather. Good parking facilities are available to the side of the property. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Maureen Brown carried out this unannounced inspection on 16th March 2006. The total time at the home was five hours and ten minutes. An hour was spent planning the inspection by reviewing the previous inspection report and the service history. The homes manager was on duty together with the agreed numbers of senior, care and ancillary staff. Twenty-eight people were living in the home at the time of the visit. During the inspection eight residents, the manager and staff on duty were spoken with. A number of residents and home records were examined and a tour of the premises, including shared areas and a number of bedrooms, was undertaken. Feedback was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? Since the previous inspection the manager has been trying to recruit additional volunteers to enable residents to have a greater involvement in the community. In addition the home is actively fundraising towards the purchase of a new mini-bus, which is nearly completed. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cotebrook DS0000026994.V284647.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 Cotebrook DS0000026994.V284647.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 Sufficient information is provided for residents to make a decision about moving into the home. EVIDENCE: The statement of purpose and service users guide called “welcome to Cotebrook” was situated in the hallway and was available to current and prospective service users. This was produced in a ring bound file and included information about the facilities, services provided, fees, terms and conditions of residence and a copy of the most recent inspection report. This guide gave prospective residents all the information they would need to make a decision about moving into the home. Current residents could also use this as a reference document as it also described times of meals, church services, hairdressing and other professional visits. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 9 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 The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: A sample of three residents’ care records were seen during this inspection. These were comprehensive and well presented in individual folders. Each contained basic information covering all areas of personal care, activities, visiting professionals sheet and a copy of the daily report sheets. The care plans seen were drawn up in consultation with the residents and family and were based on their assessed needs and risks. The residents signed their care plans to show that they agreed with the contents. Risk assessments were seen on two of the three care plans. These covered moving and handling, falls and continence. All residents must have risk assessments in place. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 10 Daily record sheets seen showed day-to-day activities of each resident. They were written clearly, easy to follow and were signed by carers. Red pen was used to detail the night care information. It was recommended this should be avoided, as it is distracting to the reader and difficult to photocopy. During discussions with the residents they said that “the care was very good” and “the home had a lovely atmosphere”. Other comments included “the food is good” and one resident said “their privacy and dignity was respected by the staff”. Residents are able to decide what they want to do and this is clearly documented in the care plans. Residents are assisted to manage their own personal finances and risk assessments are in place where limitations on choice have been identified. See requirement No. 1 and recommendation No. 1. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 11 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): 15 & 16 Routines at the home are flexible to suit residents’ individual preferences. Residents are able to maintain contact with their family and friends and make choices regarding their own lives. EVIDENCE: Residents confirmed that routines within the home were flexible and that they were able to make choices in many areas of daily living, for example, times of rising and retiring and where to spend their time. Staff members were observed to knock on the door and to await permission before entering a resident’s bedroom. The residents spoken with made positive comments during the inspection. These included “Staff are great, very kind and friendly”. Residents confirmed that they could see visitors in any of the communal areas or their own bedrooms. The manager confirmed that there are no visiting restrictions however, visitors are asked to avoid mealtimes if possible to avoid disruption to the mealtime. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 12 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): 20 The residents are protected by the procedures in place for the administration of medicines. EVIDENCE: Residents’ medication is kept in a lockable cabinet, which is kept chained to the wall in the office. The home uses a Monitored Dosage System of blister packs. The staff spoken to said they liked this system. Medication Administration Record sheets were seen and appropriately completed. A member of staff countersigns all medications. This was an extra procedure that had been put in place by the manager. All senior staff have received medication training. Controlled drugs storage is available by not currently used. The home has policies for medication and homely remedies. Excess medication is disposed of each month via the pharmacist. All medications are noted and signed by the senior on duty. The pharmacist then countersigns this list. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 13 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 Residents are able to voice their opinions and are confident that appropriate action would be taken to address any problems or complaints. EVIDENCE: There is a clear and effective complaints procedure for the home. This is included in the Statement of Purpose and Service User Guide. The welcome to Cotebrook leaflet also contains details about how to complain. The details of the Commission must be changed in the complaints procedure. The commission has not received any complaints about Cotebrook since the last inspection. The home received one complaint, details of which were seen by the inspector. The complaint was resolved to the satisfaction of the complainant. See requirement No. 2. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 14 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 & 30 The environment within the home is good, providing residents with a pleasant place to live. EVIDENCE: A tour of the premises was undertaken. This included communal areas and a number of bedrooms. Communal areas and bedrooms seen during the inspection were comfortable and well furnished. The level of personalisation within bedrooms is good. Appropriate good quality furniture and soft furnishings are provided. All bedroom doors have locks, which can be overridden in an emergency. The home both externally and internally is maintained to an adequate standard. The home was found to be clean, free from offensive odours and tidy on the day of inspection. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 15 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 Records were well maintained. Staff received support to enable them to meet residents’ needs. Recruitment policies have been consistently followed resulting in residents receiving care from staff who have been properly vetted. EVIDENCE: At the time of this inspection the agreed staffing levels were met. The home’s manager and sufficient support staff were on duty. The recruitment procedure followed ensured that all the staff employed were suitable to work with vulnerable people. Three staff files were examined and these showed that pre-employment checks were carried out. Amongst the documentation available were two references, Criminal Record Bureau checks and a medical questionnaire. Copies of certificates of courses undertaken were also available. The files were up to date and well presented. The staff team was well established. They had a range of experience and this was complimented by mandatory courses undertaken, such as moving and handling and food hygiene. Other relevant courses were also available, such as Adult protection and medication. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 16 Six out of thirty-one staff had completed NVQ level II or III in Care and ten staff were working towards this award. Three staff are NVQ assessors. The manager is working towards achieving 50 of staff qualified by 2008. See recommendation No. 2. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 17 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): 42 The arrangements currently in place fully protect and promote the residents’ safety and welfare. EVIDENCE: Safe working practices included visits from the fire safety officer and the environmental health officer, which had been completed satisfactorily. The insurance certificate was in place and up to date. Fire alarm tests were being undertaken on a weekly basis and records kept. Emergency lighting tests were also being carried out on a monthly basis with records kept. All staff had received fire awareness training. The gas safety and electrical safety certificates were up to date. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 18 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X X X X 3 X Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA6 YA22 Regulation 12 22 Requirement The registered person must ensure that all residents have risk assessments. The registered person must change the NCSC details to the Commission in the complaints procedure. Timescale for action 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA32 Good Practice Recommendations The registered person should ensure that red pen is avoided in daily records. The registered person should produce a plan to show how 50 of care staff will be qualified to NVQ II in Care by 2008. Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Cotebrook DS0000026994.V284647.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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