Inspection on 13/12/07 for Cotswold

This inspection was carried out on 13th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cotswold 30/04/07

Cotswold 23/05/06

Cotswold 07/12/05

Cotswold 20/04/05

Cotswold 15/09/04

Cotswold 29/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Cotswold Graze Hill Ravensden Bedfordshire MK44 2TF Lead Inspector Katrina Derbyshire Unannounced Inspection 13 & 21st December 2007 11:55 th Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotswold Address Graze Hill Ravensden Bedfordshire MK44 2TF 01234 772196 01234 772194 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) The Disabilities Trust Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must complete an NVQ 4 in care by 31 December 2006 Date of last inspection 16th June 2007 Brief Description of the Service: Cotswold is an adapted domestic style building situated on the edge of Ravensden village just outside Bedford town. The downstairs is made up of an office, a large open plan lounge and dining area, a kitchen, a laundry room, one bedroom and a bathroom with toilet. Upstairs there are four bedrooms of varying size, a bathroom and a separate toilet. There is a large enclosed garden to the rear. To the side there is a large double garage, with an enclosed space that could be used for activities. The home is in a secluded location with surrounding gardens and there is transport available to enable access to local facilities. The public transport service is limited to Ravensden, but there is parking available at the home. Cotswold can provide care for up to five people with an autism spectrum disorder and associated challenging behaviour in single occupancy rooms. The service is owned by The Disabilities Trust who are a national provider of services for people with autistic spectrum disorders. The home provides all aspects of people’s care, including day activities. The basic monthly fee was £1789.53 per week. There could be additions to this depending on the care needs of the person. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this visit was to undertake a key inspection. This unannounced inspection was carried out on 13th December and 21st December 2007. The newly appointed manager was present during both visits. During the inspection the communal areas of the home were seen alongside some of the individual accommodation. The inspector spent time with many of the people who live at the home in the ground floor sitting area. At the time of this inspection four people were living at the home. The care of two people was examined. Information from the home has now been provided. Evidence used and judgements made within the main body of the report include information from this visit, feedback from people who live at the home and their representatives was received through questionnaires and staff feedback. In addition information from a random inspection carried out on 16th June 2007 has been used. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. What the service does well: What has improved since the last inspection? Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 6 A new manager has been appointed and started working at the home in September 2007. Staff feel that this has been a positive change both for them and the people living here. One staff member said, “ She has changed many things, and its getting better, better for the service users”. However the manager does acknowledge that even though some changes have been made, further developments are needed to provide a person centred approach at the home. People are now given the opportunity to sit at a table to eat their meals. When we visited, people living at the home and staff sat together for their lunch. One person was seen to participate in setting the table for the meal. Only four people were living at the home when we carried out this inspection. With having one vacancy, staff feel that they have had more time to support those remaining. Activities were increasing, and people were starting to have more opportunities to participate in community resources, one person for example had recently enrolled on a course at a local college. What they could do better: There are still many things that need to change to make it better for the people living at the home. Although the new manager has started to make improvements, there are still more that must be made. Some of these include, changes to the environment. There is a bar on the living room window that prevents it from opening. The lighting in the home is not domestic in style and does not help to create a homely atmosphere. The television in the living room had been broken, and no replacement had been made. Changes had been made to people’s agreements to show that they now should pay for the transport of escorting staff and accommodation on holidays. However it was not clear if any consultation took place about this. One person had an item of their personal property broken by someone else at the home. Nothing had been done about replacing this or plans put in place so it could not happen again. People must feel that they and their possessions are safe. No further staff had been employed with the exception of the manager since we made a requirement about the way staff had been recruited, as the own policy of the home had not been followed. So we have not been able to look if this area has improved yet. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 7 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. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 8 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 Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Changes to the statement of purpose and terms of residency make clear the additional costs of living at this home, however it is not clear if the people already living at the home agreed to this change therefore their rights have not been fully upheld. EVIDENCE: On examination it was shown that changes had been made to the Statement of Purpose and the Service Users Guide; this was in response to the requirement made at the inspection in April 2007. Elements listed in Standard 1 of the National Minimum Standards and Requirement 5 of the Care Homes Regulation had been included. As previously assessed some of the information included in the Service User Guide had been produced using pictures and photos to make it user friendly to some of the people living at the home. No one had moved into the home since the previous inspection. Therefore standard two could not be assessed on this occasion. Contracts were in place for the people living at the home. Following a requirement made at the random inspection in June 2007, changes had been Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 10 made to these documents to include further information on financial matters. These changes set out additional expenses for the people living at the home, that they needed to make over their weekly fees. It was not clear however if they had been consulted in this matter and a requirement is made concerning this. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning is not sufficient to ensure continuity of care for all those living at the home. EVIDENCE: Through examination of care plans kept within the individual folders for each person it showed that there were documents in place, which briefly indicated the needs of the person. Just prior to this visit the newly appointed manager had met with the senior staff at the home to make plans to introduce person centred planning. Some changes had been made in response to a previous requirement in this area, however the manager acknowledged that this had not been met in full. One example was recorded in a person’s review that the photo activity planner needed to be replaced by person centred planning; this planner was still in use. Through discussion with staff, they confirmed that they were aware of the changes needed, as some of the guidance “could be open to different interpretation”. Staff felt that with clearer guidance all staff would Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 12 offer support in the same way to each person at the home as this had “not always happened”. Daily notes seen were written as a task list for example ‘bed changed, room clean’ rather than descriptive of the persons daily activities. As reported at the previous key inspection there again was evidence that people made some choices; menus were planned each Sunday as part of a group activity of looking through menus and pictures of meals. Where people were unable to communicate their choices, or not interested in the activity, the staff choose meals on their behalf, using their knowledge of the person and their likes and dislikes. It was also observed at this visit that one of the people living at the home participated in the organisation of the lunchtime meal, they were seen setting the table and working with the staff member who was preparing the meal. Through observation at the two visits to the home as part of this inspection, it was noted that most of the doors that had previously been reported as being kept locked, were now left unlocked. The kitchen area for example was unlocked at both inspections. However it was noted that certain staff when entering the office automatically locked the door behind them. The manager was observed talking to the staff and asking that they not lock the door. This practice was only carried out by certain staff, there appeared to be no reason for this as no risk assessment was in place to demonstrate a need for this therefore this practice should stop. Risk assessments were in place and had originally been well written as previously reported; a clear linkage to the person’s plan of care had not yet taken place. The manager advised that this would be completed as part of the introduction of person centred planning. One person was at risk of damaging televisions for example, the actions to be taken to safeguard property of the service and property of other people living at the home was not clear and is detailed within the complaints, concerns and protection section of this report. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People living at the home have a sufficient level of access to local facilities so benefit from being part of the community and having their social needs met. EVIDENCE: It had been reported at the previous key inspection that none of the people living at the home were attending education facilities. Examination of care documents and through discussion with staff it was confirmed that efforts were now being made to change this. Letters were seen to show that efforts had been made for one person to start attending a course at a local college. A letter of confirmation from the college showed that they would start their course within the next few weeks. As previously reported people also attended a ‘snoozelan’ session and others would attend a local weekly club for people with learning disabilities. Staff and records also showed that there had been an increase in activities outside of the home. At the time of the first visit people Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 14 had gone to the local swimming pool. One staff member said, “The new manager makes sure that all the staff that can drive the homes transport do so, it means we go out nearly everyday now”. All of the people living at the home has contact with their families and some go home for regular weekend visits. Feedback from the relative of one person said, “I didn’t think they were doing enough for him and l told them that, but it seems to be getting better he is getting out more and that’s what he needs”. At the time of the inspection none of the people living at the home had an advocate acting on their behalf, although there was documentary evidence to show that staff had sought this on their behalf and through placing authorities. Through discussion with staff it was advised that there had been an increase in activities and stimulation following the departure of a previous resident. One staff member said, “We have a lot more time to spend with the others now, they all have more of a chance to go out”. People living at the home were not directly involved in the preparations for lunch, but did help to lay the table at lunchtime All of the staff and the people at the home had their lunch at the same time. Most people were seen to have hamburgers and salad. Menus were in place to show that a mixture of protein, carbohydrates, dairy and fruit and vegetables were offered throughout the week. The manager and staff were observed talking with the people who live at the home, providing guidance and support throughout their meal. On examination of the food stocks at the home, it showed that levels were in keeping with an amount that would last for one week. This was supported by staff who advised that a weekly main shop was carried out and supplemented with other visits during the week to a supermarket. On the first visit the cleanliness of the fridge and freezer was poor, however this had been addressed by the second visit. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The systems in place for the ordering, administration and storage of the medication are good so people receive their prescribed medication when needed. Staff are good at supporting people to access health care support so that their health needs are met. EVIDENCE: Care records examined contained documents from a variety of medical specialists. These documents for example hospital letters, showed that people received regular support from Doctors and Nurses. Staff confirmed that they assisted people to attend hospital appointments and the outcome of any medical intervention and subsequent guidance was recorded. Feedback through returned comment cards to the Commission for Social Care Inspection showed that people felt they received the medical that they needed. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 16 The storage, receipt and administration of medication was examined. The medication administration sheets were noted to be correct. The storage of medicines were seen to be in a locked facility. Records were seen to show returns of unused medication. Staff confirmed that they did receive regular updates in the administration of medicines and observations were made of medication and noted to be appropriate and follow safe practice guidelines. Some personal care could be provided in peoples own bedrooms but because there were no washing facilities in individuals bedrooms most personal care would be provided in the bathrooms. Through observation and confirmation by returned comment cards it was confirmed that clothes and hairstyle reflected their individual personalities. Guidance and support regarding personal hygiene was offered and the level offered by staff was reflected in the care plans examined on this inspection. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is poor. We have made this judgement using a range of evidence including a visit to this service. Managements understanding and the systems in place for safeguarding adults is poor and places people at risk from abuse and not receiving the multi disciplinary support from a safeguarding team. EVIDENCE: As reported at the previous key inspection the Commission for Social Care Inspection had been informed of concerns from reviewing officers when doing reviews that actions were not put in place in a timely fashion. As described in the section two, there was still evidence of this at this inspection. It was also noted at this visit that one of the people living at the home had, had their personal television set broken by someone else living at the home. This had not been reported under local safeguarding protocols and no action had been taken by the manager to arrange a replacement for this. A discussion with the manager on the first day of this inspection showed that she had limited knowledge on incidents that must be reported under the safeguarding adults protocol, for example any physical incidences between people living at the home. Staff had attended training in 2007 on abuse and safeguarding people, documents were seen to support this. However although training had taken place the above incident had not been reported. It was also observed that a wooden bar had been secured over the window in the lounge area of the Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 18 home. This prevented the window from being opened. The manager and staff did not know why or for how long this had been in place. This is restraint and a requirement is made for its removal. The complaints procedure remained unchanged since the previous inspection. As previously reported people were aware of this procedure as complaints had been made and responded to, records of these were examined. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The décor, furnishings and fittings are not sufficient to create a homely environment for people to live in. EVIDENCE: Changes had been made to the entrance area since the previous inspection. The notice board now how information for example, about the staff that work at the home. The only sitting room had no television; the manager and staff advised that this was because a resident had broken it. Staff advised that this had been broken for “some time”, although the manager stated that they were looking into other options this had not been done at the time of this visit. The side window in this area had a fixed bar in place so it could not be opened. Lighting Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 20 in the home was not domestic in style, and did not assist in creating a homely atmosphere. None of the rooms viewed had been personalised in anyway, although it must be noted that not all rooms were seen at this inspection. All of the communal rooms were painted in a neutral colour. Bathrooms seen were functional, there were no accessories in place to personalise the rooms. The home had appropriate laundry facilities however; the laundry room was only accessible through the kitchen. Therefore, this facility was inaccessible to people living at the home without staff support. A toilet, which was also situated in this area, was said to be for the sole use of staff. The home appeared to be clean and free from offensive odours. It had been reported at the inspection in April 2007 that a re provision of the service was imminent within two to three months and that was the reason why improvements had not been made. This re provision had not taken place; the manager had not received any notification that this would be happening in the foreseeable future. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The approach and actions of some staff is not sufficient to ensure continuity of care for people living at the home. EVIDENCE: No new staff with the exception of the manager had been recruited since the previous inspection; therefore a previous requirement regarding standard 34 could not be assessed and will be looked at on the next inspection. Two staff members were on duty alongside the management in the home. Staff demonstrated an adequate level of knowledge and understanding of the people at the home and their needs. They were able to describe some of the information contained within the care records and how they should provide care and support. It was the view of some staff that other members of the team needed to improve in their day-to-day practice. When questioned further on this, they stated that some staff would arrange things to suit themselves not the people living at the home. The example that they gave was that some staff would prefer not to go out, so this would reduce the amount of activities Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 22 for the people living at the home. However they confirmed that the new manager was addressing this and they were now being made to go out. Training records seen at the time of the visits to the home showed that staff had undertaken training in the statutory areas including fire safety and medication. However two types of training course had been available to staff. Although the manager stated they were the same, one of the courses did not provide sufficient information on the specific needs of the people living at the home. Information was then submitted by the manager that showed that following the visits, training records had been updated and reflected more up to date training had in fact been undertaken. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Health and safety systems are sufficient to provide an environment for people at the home, which reduce the risks associated with this area. Although the quality assurance system has not been implemented so people have not had the opportunity to influence the running of the home. EVIDENCE: The company had employed a new manager since the previous inspection, she commenced her employment in September 2007. The new manager has previous experience of managing a care home, as she was a registered manager of another service in the Bedfordshire area. At the time of this inspection she was securing the needed documents to submit an application to Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 24 the Commission for Social Care Inspection to apply to become the registered manager of this home. All staff spoken with stated that she had made many improvements since she started work at the home. One staff member said, “ It’s been good she has been very clear that the residents come first and it’s about time we had someone like her. Some staff did as little as possible before, its all about making changes and improving things now”. Information supplied to the Commission for Social Care Inspection from the manager indicated that they have yet to complete their quality assurance audit, to gain the views of family, friends and professionals. She confirmed that the system had been devised by the company, but she had not yet commenced its use. Health and safety systems at the home were seen to be carried out in accordance with the guidance within the homes policy. The most recent fire and environmental health inspection reports show that the home had met the standards in these areas. In addition cleaning products were seen to be locked away, risk assessments had been undertaken for areas and activities in the home. Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 1 X X 3 X Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 26 YES 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. Standard YA5 Regulation 12,15 Requirement Evidence must be made available to show that consent was gained, prior to the changes made to contracts for additional financial costs. This is to ensure the rights of people living at the home are being upheld. Timescale for action 29/02/08 2. YA6 12,13,15 3. YA9 12,13 Ensure that care plans fully 29/02/08 meet the requirements of NMS 6 for Younger Adults ensuring that goals are (linked to other relevant paperwork and) broken down into measurable tasks with specific timescales, This must follow person centred planning so that each person has their individual needs and aspirations met. The reason for the office door 13/12/07 being locked by some staff must be risk assessed. This is to identify if there is a sufficient risk for this practice by some staff as they are restricting access for the people living at the home. Referrals must be made DS0000014891.V355889.R01.S.doc 4. Cotswold YA23 13 31/12/07 Version 5.2 Page 27 following the local safeguarding protocols when incidents have occurred between people living at the home. This is so that people are protected from abuse and benefit from the support of the multi agency safeguarding teams. 5. YA24 13(7) , 16 & 23 The removal of the bar from 29/02/08 the sitting room window must happen. Re decoration and changes to the environment must be made so that the people living at the home have a pleasant and homely environment in which to live. 18,19,CSA A more robust approach to 13/12/07 2004Schedule recruitment should be adopted 2 both in terms of the detail of information required and the need to follow up if the information provided is not satisfactory or gives cause for concern. (Previous requirement not able to be assessed at this inspection) 6. YA34 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Cotswold DS0000014891.V355889.R01.S.doc Version 5.2 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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