Inspection on 23/05/06 for Cotswold

This inspection was carried out on 23rd May 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cotswold 13/12/07

Cotswold 30/04/07

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 Mr Paul Worthy Unannounced Inspection 23rd May 2006 12.50 Cotswold DS0000014891.V292895.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 Cotswold DS0000014891.V292895.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. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 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 Mr John Masterson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 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 7th December 2005 Brief Description of the Service: Cotswold is an adapted family home 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. It contained a small gym and a ball pool. 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 individuals 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 service users 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.V292895.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 12.50 p.m. and lasted, over two days, a total of twelve hours. Prior to the inspection, the manager had returned a pre-inspection questionnaire and some questionnaires sent out to relatives had been returned. Clarification of some of this information was obtained by telephoning some of the relatives. This pre-inspection information along with the history of the home since the last inspection was taken into account in planning the inspection. The services provided to two service users in particular were inspected. The inspector met during the two days with four members of staff and on various occasions the manager. The manager showed the inspector round the building accompanied at times by various service users. Two of the service users showed the inspector with the manager their rooms. The inspector also looked at relevant records and observed the interaction of those living at the home with the staff and the way they moved around the building and grounds. The ability of those living at the home to communicate was limited so that the inspector was dependent on observing the interaction between the staff and the service users to determine what the outcomes for the service users were. The inspector would like to thank the manger, staff and those living at the home who participated in this inspection. What the service does well: The manager and staff were seen to be working in very positive and creative ways to support people with autistic spectrum disorders. The basis of this was firstly to allow the service users as much freedom of movement as possible within the home, for example the kitchen and the office is now normally open to them. Secondly, to support them in what they were choosing to do or to find ways to provide an acceptable alternative. An important component of providing this support was seen to be the ability of the manager and staff to understand what a service user wanted and to take time to try and achieve this, while not inadvertently triggering repetitive patterns of behaviour. The basis for the approach being taken to create real choice for those living at the home was seen to be the trusting and positive relationships the staff and service users had with each other and the patient way work was being undertaken to establish that trust. The evidence of their success was to be seen in the degree to which the personalities of the service users were allowed to show themselves and their pleasure in their freedom and ability to act on their own terms. Manager and staff were to be commended on what they have and are achieving. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cotswold DS0000014891.V292895.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 Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were arrangements in place to ensure that prospective service users would be appropriately assessed so that it would be known if their needs could be met and to provide transparency about the services to be provided. EVIDENCE: The statement of purpose, which was seen, had been recently updated. It made clear the specialised work of the home in meeting the needs of people with autism spectrum disorders. There was a service users guide that used pictures to complement the written information and a contract that used symbols to help make it understandable. A complaints policy was on display in the entrance area, which used pictures and was intended for two of the service users who, it was thought, would be able to gain some understanding from it. The manager noted that there was ongoing work to ensure that the attempt to impart information would be individualised to reflect the understanding and communication routes available to each individual service user. The files seen had Social Service Care Plans on them, which provided initial assessment and planning information. The Statement of Purpose contained appropriate procedures for dealing with new referrals. Cotswold DS0000014891.V292895.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was appropriate assessment and planning for meeting the needs of those living at the home to ensure that as far as possible this was consistent with their choices while helping them to remain safe. EVIDENCE: All the personal files that were seen had been recently rationalised to make the contained information accessible. There was comprehensive assessment and planning information relating to those living at the home contained in a number of documents. The documents included a service users plan, risk assessments, very comprehensive guidelines for caring and supporting service users. There was also a separate sheet providing information relating to health care and medication, and an activities sheet, which clarified the objectives in respect of activities. There were also letters from various professionals advising on the best way to work with a particular person. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 10 The staff who were spoken to were all very well informed on the current needs of the service users and it was clear that the arrangements for ensuring updating, consistency and continuity of care were working very well. The key worker system was an important part of this. Each person living at the home had two key workers who often worked together, for example when taking someone on an outing, and also divided the responsibilities in ensuring that the person received the support that they needed. An excellent meeting note by two key workers for a service user was seen, which specified the division of labour and outlined a plan of work with the person, including activities. This was seen as very good practice. There had been monthly reports produced by key workers in the past, which reviewed the progress in meeting the goals of the service users plans and updated the assessment and planning information as required. There were annual reviews being carried out by the placing authorities. These were of a variable nature with some doing comprehensive whole life reviews (although in one case only every two years) and others merely rubber-stamping the original placing agreement and not taking account of the complexity of the persons needs. The manager having achieved his first goal of rationalising the files had started work on rationalising the assessment and planning information. It was clear talking to staff and the manager that there had been a major change in the approach of the home. Prior to the manager coming there had been, through risk assessing, emphasis on what could not safely be done with service users and the need to keep parts of the house locked so that they did not have free access. This had changed so that the times those living at the home become frustrated has been reduced and is being further reduced as the manager and staff increase their ability to understand them. The aim to allow those living at the home to live as normally as possible but in a risk assessed context to ensure their and others safety continued but with a strong emphasis on determining if the risk had been as real as previously claimed. The manager confirmed that the way to take forward person centred planning so that it genuinely reflected the needs of the people living at the home was being looked at. Work was seen on the files to build up histories of people with the help of their relatives, as a first step in creating life-story books. The aim to give genuine ownership of the person centred planning approach to those living at the home was seen as very good practice. Cotswold DS0000014891.V292895.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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were working extremely well with the people living at the home to normalise their lives as much as possible and respect their choices so that they could live lives that were as full as possible. EVIDENCE: The activities identified in the assessment and planning information showed that staff were maintaining and developing social, emotional, communication and normal living skills. The manager and staff were observed to work in a patient and imaginative way with the service users to achieve this. The activities included access to the community, including trips to local pubs, shops and swimming pool. There were a variety of indoor activities and these were now held in accessible boxes, so that those living at the home could indicate what they wanted to do. A staff member was seen helping someone do a jigsaw, which they were clearly both enjoying and which provided an opportunity for good interaction. There was a range of leisure activities both in Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 12 the home and involving trips out. It had in the past been the view that no one living at the home would be able to cope with holidays. The manager and staff were exploring the possibility of two service users having holidays during the summer. The staff were enthusiastic about these developments. The home had a minibus but the manager and staff noted that a larger one was replacing it and that this would increase their capacity to provide outings to those living at the home. The manager and staff drew attention to the problems of obtaining appropriate day care or educational provision for people with autistic spectrum disorders. The manager confirmed, however, that work was being undertaken with the local college for one of the service users to start attending the college. They were working with the college and the person to ensure that the persons needs could be met. Appropriate social space was being given to those living in the home to follow through on activities in the ways that they were comfortable with and to work with them in this way to undertake everyday activities such as helping in domestic tasks, for example, helping to clear up after meals or to help in washing up. Both of these activities were observed and staff were seen to be supportive and encouraging without in any way coercing. The mealtime was seen to be a social occasion with the service users and staff being together. There were weekly meetings with those living at the home to decide on, amongst other things, the weeks meals. Pictures had started to be used to help in the decision-making. Substantial and well-presented meals were seen to be served. Staff confirmed that those living at the home that had contact with families were being well supported in maintaining the contact. The manager and staff appreciated the help and support from relatives. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good arrangements to ensure that those living at the home remained well cared for in respect of their personal needs and there healthcare so that their wishes and dignity were respected and they enjoyed good health. EVIDENCE: The assessment and planning information covered service users needs for personal and health care in detail. There were very good arrangements for ongoing monitoring of the health of those living at the home, including regular monitoring by the consultant. The records and talking to staff provided evidence that the staff were proactive in obtaining medical help when confronted with health problems. The MARs sheets were seen and showed that there were good arrangements for managing medication. Staff spoken to explained the induction training that was provided relating to medication. The pharmacist also sent out a questionnaire and on this basis was issuing the staff with a certificate to say that they were competent. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 14 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good arrangements to allow the manager and staff to identify and respond to any distress on the part of those living at the home and to pick up on issues that required activating the protection of vulnerable adults procedures so that the service users and their representatives would remain satisfied with their care and remain satisfied that they were protected. EVIDENCE: Talking to staff it was apparent that a lot of effort went into identify the causes of concern, unhappiness or stress that those living at the home might have. The close relationship they had with the service users made it possible for them to become aware of distress and increasingly to be able to identify the cause, in particular where their frustration was due to a failure to communicate their wishes. Talking to staff showed that there was an appropriate knowledge of the local POVA protocol. There was an appropriate policy and procedure complemented by the local protocol. There was appropriate training for staff for dealing with aggressive behaviour. Staff said that the stress was on avoiding such situations where possible or defusing them. They confirmed that they had had appropriate training and Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 15 that there had been a significant reduction in the number of incidents of this nature. This was particularly the case with incidents arising from a failure to understand what service users were indicating they wanted or restrictions imposed on their freedom of movement around the house Attempts were seen to have been made to find ways in general to pass information and about complaints and protection in particular to those living at the home. An illustrated complaints procedure was seen on the notice board specifically for two of the service users. Further work was planned to determine what level of complexity could be achieved in the message and the best way of getting the message across for each service user. The manager stated that the Social Services Department was acting for those service users who did not have representatives to act as their appointees in respect of their financial matters, which meant an external overview, which added an element of protection for them. Recently they had all had bank accounts opened in their names. There was ongoing work to ensure that there were two staff signatures when money was withdrawn from a service users bank account. In one case the service user was signing as the additional signatory. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 16 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, 25, 26, 27, 28, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided a suitable home for the people living there so that they were comfortable and their independence was encouraged. EVIDENCE: The accommodation was seen to be appropriate to the needs of the service users. It had a homely and comfortable feel. Those living there were seen to be relaxed in it and free to wander within the building as they wished. They had access to their bedrooms as they chose. The two bedrooms seen reflected the wishes of the service users and their tolerance of furniture. In one case there was a range of furnishings and the room was individualised. In the other there was ongoing work with the person whose room it was, at their pace, to help them become more tolerant of furniture. The provider had to make the garden more secure so that those living at the home could have free and safe access to it. Staff commented on the refurbishment work that had been going on and the way this had improved the feel of the home. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 17 There were appropriate toilets and bathrooms and staff were seen providing support to service users to encourage them to protect their own privacy. There was an appropriate kitchen with a new large oven and a laundry that the service users were seen to use. The kitchen had been kept locked but was now open except when the hob was being used and any service user in the kitchen needed close support. The home was observed to be clean and fresh. It was observed that there was only one lounge area for activities so that there was no provision of alternative spaces in the public areas, which would have helped, given the strong need of the service users to determine their own social spaces and choice of activities. It also meant that there were no alternative spaces to their bedrooms, in which the service users could meet privately with their relatives. The move to secure the garden, would during summer months, help these problems, but they would still restrict the capacity of the home to diversify the day care within the context of the home. During the inspection, however, it was seen that the manager and the staff were doing their best to overcome these limitations and the open door policy and accessibility of bedrooms was helping a lot. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 18 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): 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing arrangements and ensured that the needs of the service users could be met, given the resources available. EVIDENCE: Staff confirmed that the home was almost fully staffed and there were good arrangements for using the Trusts bank staff, which ensured that when they were needed it was someone whom the service users knew. Agency staff were not usually used. The staff confirmed that the intended staffing numbers were maintained on a daily basis and that this allowed them scope to follow through on plans for those living at the home. A strong supportive team spirit came across talking to the staff and a strong affection for those living at the home and awareness of their complex needs. There was also a strong sense of wanting to take things forward to improve the quality of their lives. The manager had recently rationalised the staff files so that they held all the required information in an accessible form. This had shown up some gaps in the information and joint work was under way to ensure that these records were passed on from personnel. The arrangements in place relating to Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 19 recruitment were seen from these records to be appropriate. The arrangements for obtaining references had moved to asking only for a checklist to be completed, which had not encouraged more nuanced replies from the referees. It was also noted that some previous employers references, in particular agencies, disclaimed any knowledge of the working practices of the person. There was no evidence of following up with a phone call to the referee or asking the applicant for a further referee. Staffing records showed that appropriate arrangements were seen to be in place for initial induction training, including LDAF based training, and for mandatory training, including updates and other training. Staff confirmed this to be the case. Training included working with people with autistic spectrum disorders. Much of the homes training was provided by trainers from the provider, but where this would lead to delays the manager could use local training organisations, and was planning to do so for the next round of training. One member of staff was training to be an NVQ assessor so that the NVQ training could be taken forward more easily. There were arrangements for annual assessments of staff aimed at helping them develop their knowledge and skills. Records also showed that there were good arrangements in place to support staff and ensure continuity and consistency of care and support for the service users. This included handover meetings, one of which was attended. This showed that it was an effective way of ensuring continuity between shifts and gave staff the opportunity to share thoughts about the support of the service users. There were good arrangements in place for supervision, including a wall chart that was seen that enabled the manager to keep track of them and ensure that sight was not lost of those that were cancelled. There were also staff meetings and staff said that the manager had an open door and was very supportive. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43 Quality in this outcome area is satisfactory. This judgement has been made using available evidence including a visit to this service. There were good management systems in place, which ensured that the service users were enabled to live their lives as fully as possible. EVIDENCE: The registered manager was seen to be providing excellent, supportive and visionary leadership to the home. The staff spoken to confirmed this. The vision, which the staff clearly shared and were enthusiastically realising, was that of treating all the service users as individuals and recognising the significance of their actions, and the frustrations that lay behind some of the more disruptive ones. The important steps in this had been to identify where the frustrations lay, in particular the locked doors in the home and the failures to understand service users’ wishes. Talking to the manager and the staff showed that this vision of working with the service users was an ongoing development plan to improve the service for Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 21 those living at the home, based on a clear analyses of the problems reflected in the disruptive behaviour of those living at the home that needed to be overcome. There was also work to empower the staff to work in positive and constructive ways with the service users. This reflected a thought out and shared development plan to improve the service to those living at the home, which reflected their wishes. This had not, however, been formalised into a quality assurance system that co-ordinated arrangements the monthly reports produced on behalf of the provider, monitoring, reviewing and producing an annual development plan linked appropriately to a business plan for the next year. The manager said that having worked on developing the records and laying a foundation by this for ongoing improving of all areas of recording, the next major project was to ensure that the home had an appropriate quality assurance system in place. The documentation showed that there were good arrangements for monitoring health and safety matters within the home and ensuring that those living in the home remained safe. It was, however, noted that the checking of the fire alarms was not being carried out on a weekly basis. Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 2 x Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 10/06/06 1. YA42 23 Ensure that the fire alarm system is tested weekly. (Previous timescale of 31.5.05 not fully met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The service users plan should contain all the main information or cross reference to it so that it can be effectively reviewed on a regular basis. The policy and procedure relating to requests, concerns and complaints should address the problems that service users may have understanding such a procedure. It also needs to address the difficulty they may have to effectively communicate concerns. The policy and procedure should draw attention to the role that relatives, advocates and staff will have in ensuring that the service users rights are safeguarded. It should also note the role of the quality assurance arrangements to alert the manager to service DS0000014891.V292895.R01.S.doc Version 5.1 Page 24 2. YA22 Cotswold deficits that need to be taken into account. 3 YA34 A more robust approach to references should be adopted both in terms of the detail of information required and the willingness to follow up if the information provided is not satisfactory either by contacting the referee or asking the applicant for an alternative referee. Steps should be taken to formalise the present monitoring and reviewing systems that are in place to ensure that they meet the regulation and standard relating to quality assurance and result in an annual development plan appropriately linked to the business plan. 4. YA39 Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Cotswold DS0000014891.V292895.R01.S.doc Version 5.1 Page 26 - 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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