Inspection on 07/12/05 for Cotswold

This inspection was carried out on 7th December 2005.

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 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 28 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 23/05/06

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 Rachel Geary Unannounced Inspection 7th December 2005 02:05 Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 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.V266810.R01.S.doc Version 5.0 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.V266810.R01.S.doc Version 5.0 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.V266810.R01.S.doc Version 5.0 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 20th April 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. 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 with autistic spectrum disorders. The home provides all aspects of service users care, including day activities. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, and took place between 14:05 and 19:15. The inspector met service users, spoke to staff on duty - including the manager, observed practice, looked at records, and had a partial tour of the premises. Due to their disabilities, the service users were not able to talk about their care. What the service does well: What has improved since the last inspection? What they could do better: There are a lot of things that the home could do to improve the service that is provided. As previously reported, at the moment, the home cannot show how Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 6 it is suitable to meet the particular needs of people with autism. Clear care plans are needed to enable staff to meet the service users’ holistic needs. There must also be meaningful activities to help service users develop their independent living skills, and to keep them interested and occupied. Another important task is making sure that all information given to service users and their families/representatives is clear and easy to use. In addition, further environmental improvements are required. Finally, the service must continue to develop current paperwork and systems for staff and service users, to make sure that they are meeting legal requirements, and the Government’s standards for services such as Cotswold. 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.V266810.R01.S.doc Version 5.0 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.V266810.R01.S.doc Version 5.0 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, 3 and 5. There was still limited evidence that Cotswold provides a specialist service for individuals with an autistic spectrum disorder. For example, there was little emphasis given to enforcing ordinary life patterns and expectations. EVIDENCE: A Statement of Purpose had been developed, however some of the information within this document was now out of date. A Service User Guide was not found on this occasion. Although service users did not communicate verbally, there was some evidence that they were able to make their needs known to the staff. One example of this was one person who put their shoes on to indicate when they wanted to go out. However, a letter from a chartered psychologist, dated January 2005, outlined significant concerns regarding the home’s ability to meet the needs of one service user. The letter stated that staff at Cotswold needed to develop and maintain a comprehensive timetable of activity (including outdoor activities), appropriate to the person’s needs and interests. It went onto say that such a strategy would be greatly assisted if all staff had the opportunity to undertake specialist training in autism and Makaton (sign language), to empower them, and to provide a specialist service appropriate to the person’s needs (see ‘staffing’ section later in this report). The letter continued by saying that the person’s challenging behaviours appeared to directly relate to them residing at Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 9 Cotswold, and that the home had insufficient specialist resources to meet their care needs. From the start of this inspection, the service user in question indicated that they wanted to go out. This did not happen until the evening because staff stated that the person had already been out for a walk earlier in the day, there were not enough staff during the afternoon, and then later, it was too dark. Eventually the service user was supported to go out for a drive, and to buy some toiletries from a local supermarket. Although the manager described a number of measures that the home was implementing to address the deficits outlined in this letter, there was still significant evidence to suggest that the majority of these concerns remained at the time of this inspection. Attempts to make Service User Contracts user-friendly had been made, however; they did not contain all the required information, as set out in Standard 5 of the National Minimum Standards (NMS) for Younger Adults (1865). There was also no evidence that service users, or an appropriate representative had signed contracts. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7. Care plans do not provide adequate information to enable staff to meet the holistic needs of service users. EVIDENCE: As previously reported, care plans did not provide adequate information to enable staff to meet the holistic needs of service users. Although some useful information was available, it was not always up to date. Information was also disorganised, and there was a fair amount of duplication. There was no evidence of service user/service user family/representative involvement in the development of care plans, and plans had not been designed to be user friendly. In addition, a number of restrictions for service users were in place, but these were not always referred to within care plans. Where personal goals had been identified, they had not been broken down into measurable tasks with specific timescales. The home had also not begun the PCP (person centred planning) process with any of the service users. The manager explained that he was taking the care planning process back to basics, and as a result, was in the process of arranging individual professional assessments for each service user. It was said that all service users had had a Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 11 review of their care needs since the last inspection however; the minutes of these meetings were not available for all service users. There was little evidence that staff encouraged service users to complete tasks for themselves. In addition, although a number of risk assessments were in place, these had not been reviewed for over 2 years. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14 and 16. Service users had limited opportunities for personal development, and there was still evidence of a restrictive culture within the home. EVIDENCE: See also previous ‘choice of home section’. None of the service users were able to work, and regular opportunities to attend structured external day care activities were low. At the time of this inspection, staff from the home were continuing to provide all activities. It was discussed that a member of staff had recently met with a community access officer to look at increasing opportunities for service users to access a variety of meaningful activities. It was also said that individual activity programmes were in the process of being set up. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 13 On the day of this inspection, there were no planned external activities although it was said that some of the service users had been out for walk earlier in the day. One service user was supported to do part of a jigsaw puzzle and play a game of dominoes. Otherwise, service users were observed to be sitting or wandering around the home and the garden. An activity record for one service user indicated that they had recently participated in the following activities: shopping, relaxing and listening to music, pacing in and out of the home, watching TV, making lunch, out for a drive and lunch out, having a bath and making a bed, Corner Club, going outside in the garden, snoezelen, having a foot spa, doing a jigsaw puzzle, and going for a walk. There was evidence that some of the service users were being supported to make Christmas cards to send to friends and family. It was discussed that service users did not go on holiday. The manager said that he intended to address this. The home had its own transport, however, at the time of this inspection, it was said that the majority of the staff team could, or would not, drive this vehicle. It was said that during the day, staff would support service users to use the local bus service. Service users did not have free access to the kitchen, laundry, a staff toilet, the office, or the grounds to the front of the home. As previously reported, although it is said that restrictions are in place due to the risks to service users, the specific risks were not always indicated on service users’ records and some service users were subject to restrictions due to the needs of others in the home. One person had some cooking guidelines in their file, but was not actually participating in meal preparation in the home. The manager discussed ways to eliminate any unnecessary restrictions, on a risk assessed basis. On a positive note, changes had been made with regard to menu planning, which included increased involvement from service users. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 14 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 and 19. Service users’ personal and health care needs are generally well met. EVIDENCE: The majority of staff were observed to be supporting service users in a way that was respectful and unhurried. However, one person was observed to ‘guide’ one service user away from the inspector quite firmly, and another took an item away from the same service user without reasonable justification (see also ‘staffing’ section later in this report). There was evidence that the home accessed outside healthcare professionals and services as required, in order to meet the healthcare needs of service users. There was still no evidence that any staff had received training with regard to medication administration. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 15 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. Arrangements to protect service users are in place. EVIDENCE: The Statement of Purpose contained some information relating to the home’s complaint process however; this did not adequately meet the requirements set out in standard 22 of the NMS for Younger Adults (18-65). Previous concerns about the signatory arrangements for withdrawing money from service users’ bank accounts, and the fact that they were paying tax on the interest accrued, were being addressed. The manager had arranged for some new card accounts to be opened, and for the financial control of service users finances, to transfer to them and/or the placing authority (as appointee), with appropriate day-to-day support from staff. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 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 and 30. A number of improvements have been made to the premises since the last inspection, but further work is still required. The current layout of the home means that service users do not have free access to some of the communal facilities. EVIDENCE: Some improvements had been made to the environment since the last inspection of this home. It was said that a full refurbishment (including works to the bathrooms and kitchen), had been carried out. The manager also said that he had plans to improve access for service users within the grounds by replacing the front gate, and fitting a device to alert staff of anybody coming in and out. Service users’ bedrooms were not seen on this occasion. Despite the improvements, it was noted that the new oven was too small, and the flooring in the toilet on the first floor was in a poor state of repair - and infection control was compromised. In addition, there was an iron burn mark on the lounge carpet, and some of the decor in communal areas required refreshing. Furthermore, there were no window coverings at the front door or bathroom windows. There was also no working lock for the downstairs Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 17 bathroom, and no toilet paper, soap or method of drying hands. It was said that this was all because of the specific behaviours of one or more of the service users. However, it was also discussed that there was more that could be done to address these matters, and to promote good hygiene, and the right to privacy within the home. The temperature within the home was noted to be chilly. A member of staff addressed this. The local Fire Authority last inspected the home on the 20th October 2005. The subsequent report stated that ‘the existing fire safety measures were being satisfactorily maintained’. The home had appropriate laundry facilities however; the laundry room was only accessible through the kitchen. Therefore, this facility was inaccessible to service users 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. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 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 and 35. Once again, there was evidence that the support to service users was inconsistent, and that staff did not all communicate and work with the service users in the same way. EVIDENCE: The manager said that the home had a core group of staff who had worked at the home for some time. In addition, a number of new staff had recently been appointed, which meant that there was now a full complement of staff. It was also said that a new ‘key worker’ system had been introduced, and that team meetings had been re-established. On the afternoon of this inspection, there were 4 staff on duty (although this reduced to 3 between 3pm and 4pm), to support the 5 service users. It was discussed that there are usually 4-5 members of staff on each shift. It was also said that 4-5 staff are required on duty to support service users to access external activities. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 19 The attitudes and characteristics of staff differed. On one hand there were a number of staff, including the manager, who were able to demonstrate their commitment to the service and the service users. These people spoke with enthusiasm about their roles and about how they felt that they could support the service users to achieve their full potential. They were also observed to be attentive and respectful, and spoke to service users as they supported them. However, there were also staff members who did not appear to have a clear understanding of the main aims and values of the home. These people demonstrated less positive interaction with the service users. The manager said that training in non-verbal communication systems, including Makaton, had been arranged for the majority of the staff team. There was evidence that staff training was taking place and some copies of training certificates were found. However, individual training records were not always in place, or up to date. Because of this, it was not possible to verify what training all the staff had received. A staff training and development plan was also not found on this occasion. On a positive note, a new member of staff confirmed that she was working through a LDAF (learning disability award framework) induction programme, and another stated that she had achieved an NVQ 3. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 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 and 39. Although slow progress had been made in a number of important areas, the manager demonstrated clear leadership skills, and an excellent understanding of the areas in which the home needs to improve. EVIDENCE: Since the last inspection, Mr John Masterson, had been appointed as manager, and had successfully completed the CSCI registration process. A number of positive comments were made about the new manager from staff who appeared to share his values and vision for the service. The manager acknowledged that there is a lot to do, and explained how he intended to address some of the ‘old style’ and unsuccessful practices, that have resulted in a reported increase of non compliance, following recent CSCI inspections. A quality assurance and monitoring system that conformed to the relevant regulation and standard was not found on this occasion. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 21 Reports of the provider’s visits under regulation 26 were being received however, as previously reported, these did not adequately report on matters arising as a result of these visits, or actions being taken with regard to addressing outstanding inspection requirements. A fire logbook indicated that the fire alarm and emergency lighting systems were still not being tested at the required intervals. A member of staff pointed out that tests were being arranged in the diary, so perhaps they had been done, but not recorded. A fire drill had taken place in October. Previous concerns regarding the use of correction fluid on medication administration records had been addressed. A business plan specific to the service at Cotswold was not found on this occasion. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X 1 X 2 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 1 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 2 LIFESTYLES Standard No Score 11 1 12 X 13 X 14 2 15 X 16 1 17 Standard No 31 32 33 34 35 36 Score X X 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cotswold Score 2 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 1 X X X X DS0000014891.V266810.R01.S.doc Version 5.0 Page 23 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 YA6YA2 Regulation 15 Requirement Timescale for action 31/03/06 2 YA24 23 3 YA33YA3 12 Ensure service users plans cover all areas detailed in standard 2, including needs in relation to their environment. (Previous timescales of 31.1.05 and 31.7.05 not met). 31/03/06 Ensure that there are robust arrangements to maintain the environment of the home in good repair, which reflect and meet the needs of the service users. Provide an action plan detailing when the following items will be completed: repair of the wooden unit enclosing the sink pedestal in the first floor toilet and replacement or redecoration of the rusty radiator covers. (Previous timescales of 31.1.05 and 30.6.05 not met). Review the care practices 28/02/06 in the home to ensure that they are based on current best practice for DS0000014891.V266810.R01.S.doc Version 5.0 Page 24 Cotswold 4 YA16YA9YA7 12 and 13 5 YA14YA13YA12YA11 16 6 YA20 13 7 YA38YA32YA31YA36 12 and 18 8 YA39 26 people with autistic spectrum disorders.(Previous timescale of 31.7.05 not fully met). Expand the scope of risk assessments to include service users known and likely activities and include any restrictions on choice or freedom necessary to manage identified risks.(Previous timescale of 31.7.05 not met). All service users must be enabled to take part in meaningful activities and records must be kept of activities provided, and accessed. (Previous timescales of 31.12.04 and 31.7.05 not fully met) Staff must be trained in the administration of medication. (Previous timescale of 31.8.05 not met). Staff must receive supervision, support and guidance to understand and implement the aims of the home and to provide consistent care to service users. (Previous timescale of 31.8.05 given, but not assessed on this occasion). Review the quality and reporting of visits made under regulation 26 to ensure that significant issues affecting the quality of service provided are identified, and action taken to address them. (Previous timescale of 31.5.05 not met). 31/03/06 31/01/06 31/01/06 31/12/05 31/12/05 Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 25 9 YA42 23 10 YA1 4 and 5 11 YA5 5 12 YA6 15 13 YA30YA24YA18 12, 13 and 23 Ensure that the fire alarm system is tested weekly, and that the emergency lighting system is tested monthly. (Previous timescale of 31.5.05 not fully met). Update the current Statement of Purpose and Service User Guide. Please forward copies to the CSCI on completion. Update the current Service User Contracts to ensure they fully meet the requirements set out in NMS 5 for Younger Adults (18-65). Service user care plans must meet all the requirements as set out in NMS 6. Ensure that there are robust arrangements to maintain the environment of the home in good repair, which reflect and meet the needs and rights of the service users. Provide an action plan detailing how and when the following matters will be addressed: The lack of window coverings at the front door and bathroom windows, the small oven, the décor within communal areas that requires refreshing, improving access throughout the home and grounds for service users, maintaining a comfortable temperature at all times, the iron burn mark on the lounge carpet, repairing 31/12/05 31/03/06 31/03/06 31/03/06 06/01/06 Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 26 14 YA22 22 15 YA35 18 16 YA39 24 the flooring in the 1st floor toilet, and providing a working (overridable) lock, toilet paper, soap and a method of drying hands in the ground floor bathroom. Ensure the home’s complaint procedure fully meets the requirements set out in NMS 22. Ensure that there is a staff training and development plan which includes induction, mandatory, specialist and NVQ training for all staff. Individual staff training records must also be maintained with evidence, such as copies of the certificates of attendance. Ensure that there is a quality assurance and monitoring system that fully meets the requirements set out in NMS 39. 31/03/06 28/03/06 30/04/06 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 Refer to Standard YA23 Good Practice Recommendations The manager should countersign incident records and include action to prevent a recurrence. (This is a recommendation from the 20.4.05 report. It was not adequately assessed on this occasion). There should be two signatories on service users bank accounts to minimise the risk of abuse. (This is a recommendation from the 20.4.05 report. It had not been fully met on this occasion). Service users should be supported to claim for tax DS0000014891.V266810.R01.S.doc Version 5.0 Page 27 2 YA23 3 Cotswold YA23 4 5 YA14 YA43 exemption on interest accrued on savings. (This is a recommendation from the 20.4.05 report. It was not adequately assessed on this occasion). Service users should have the option of a holiday, outside of the home, each year. A business and financial plan should be developed, specific to the service at Cotswold. Cotswold DS0000014891.V266810.R01.S.doc Version 5.0 Page 28 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. 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