Inspection on 27/09/06 for Cotswold Cottage

This inspection was carried out on 27th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cotswold Cottage 21/11/05

Cotswold Cottage 04/05/05

Cotswold Cottage 02/08/04

Cotswold Cottage 29/04/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Cotswold Cottage Grange Road Hazlemere High Wycombe Bucks HP15 7QZ Lead Inspector Sue Smith Unannounced Inspection 27th September 2006 12:30 Cotswold Cottage DS0000022965.V304077.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 Cottage DS0000022965.V304077.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 Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotswold Cottage Address Grange Road Hazlemere High Wycombe Bucks HP15 7QZ 01494 527642 01494 527642 manager.cotswold@fremantletrust.org Manager.winglodge@fremantletrust.org The Fremantle Trust 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) Diane Bryant Care Home 8 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: Cotswold Cottage is a detached property located at the end of a quiet residential road in Hazlemere, High Wycombe. The home is run by The Fremantle Trust and is registered to provide accommodation for up to eight people with learning and physical disabilities. The home is near to local shops and public transport links into High Wycombe and Amersham. Cotswold Cottage has eight single bedrooms, some on the ground floor, and two lounge areas. There is a large kitchen/dining area and sufficient bathrooms and toilets. The home has an enclosed garden and overlooks farmland to the rear. Each person living at the home has considerable care needs and the home has appropriate aids and adaptations to assist with daily living tasks. The current Service User contribution towards fees is £62.35 per week. Information pertaining to the current fees was received from the Home on the 21st August 2006. Additional costs exist for such things as hairdressing, newspapers and personal toiletries. Information to support potential Service Users and their families to make a decision for admission to the home is provided in the homes Statement of Purpose and the Service Users Guide, which are provided to potential Service Users, with additional copies held in the home. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the service since the implementation of IBL2 (Inspecting for Better Lives). The inspection was undertaken on the 27th September 2006 by Sue Smith (Regulatory Inspector). The Manager was available throughout this inspection. The Inspector used a triangulated methodology to complete this inspection, pre-inspection information and documentation was used in the planning process to ensure hypothesis were formulated to support the inspector to explore issues of concern and verify practice and service provision. During the inspection a variety of documentation was assessed, which included Careplans, Risk Assessments, Monitoring tools, Medication procedures, Rota’s, Recruitment files and Training records. The Inspector for Case Tracking purposes identified three Service Users. As a result of this inspection two recommendations were made to support the home to further improve its practice. Some of the Service Users at Cotswold Cottage have limited verbal communication skills, which necessitated the Inspector spending time observing the practice of staff and how they interacted with the Service Users. Throughout these observations the Inspector found staff to be professional when carrying out their duties, the Service Users were relaxed and enjoyed the company of the staff. Staff work hard to provide a homely and relaxed atmosphere for Service Users. Feedback was received from families through comment cards, feedback was positive on all comment cards with most generally satisfied with the care provided at the home, concerns with staff shortages were raised through comment cards, it is hoped the recent recruitment of staff at the home will now alleviate this problem. The Inspector would like to thank the Service Users Staff and Management for the warm welcome received, and their support in completing this inspection. What the service does well: The home only admits service users after a thorough admissions and assessment procedure has been undertaken. The home provides regularly reviewed individual plans of care to support Service Users, ensuring the identified and changing needs of Service Users is met. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 6 The home ensure Service Users are able to access a wide variety of community and in-house activities, ensuring there are opportunities made available to maintain their friendships and relationships. Meals and snacks offered are of a high standard, those service users requiring additional support are given this support in a sensitive manner. The home ensures all of the identified healthcare needs are met and changing needs are identified and action taken. Robust medication procedures are in place to protect Service Users. The home has a comprehensive complaints procedure, which is reflective of timescales for action. All staff receive Protection of Vulnerable Adult training with a policy in place to support staff to provide a safe environment for the Service Users. The home is well maintained providing a pleasant and homely environment for Service Users. The home has a robust recruitment procedure maintained by the Organisation, which protects S.U. The home has a training programme, which supports the professional development of staff. The home is managed by a suitably qualified and experienced manager, who ensures the home is run in the best interest of the Service Users. The home has robust Health and Safety systems in place, which protect Service Users. The home has a clear quality audit system in place, which supports the improvement plan for the home. What has improved since the last inspection? Recent recruitment of staff has alleviated the pressures of ensuring suitable numbers of skilled and experienced staff are available to support Service Users. A new Deputy Manager has been employed to support the safe management of the Service. The home continues to offer a sensitive and professional service to its Service Users. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 7 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 Cottage DS0000022965.V304077.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 Cottage DS0000022965.V304077.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The Organisation operates a thorough admissions procedure, which ensures the needs of any Service User admitted to the home, can be met. EVIDENCE: The Organisation has a clear policy in place for the admission of Service Users. All admissions are based on assessment following a referral from the Community Learning Disability Services Team. The admission procedure is reflective of consultation with the Service User, family members and significant other professionals. In addition consultation takes place with the existing Service Users to ensure compatibility following trial visits. There are no restrictions on admission based on culture, religion or sexuality, all admissions ensure the equality and diversity of the individual is taken into consideration through the assessment process. There have been no recent admissions to the home. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 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, 7 & 9. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home provides regularly reviewed individual plans of care to support Service Users, ensuring the identified and changing needs of Service Users is met. Service Users are supported to make decisions that affect their day-to-day lives in a method of communication that suits their needs. Risk assessments are in place, which support Service Users to maintain their levels of independence. EVIDENCE: The home provides individual plans of care for each Service User; these are reflective of ongoing review with all documentation found to be up to date and relevant to the needs of the Service User. Individual Support Plans are in place for identified needs following the assessment process, at this time these are not reflective of the personal preferences of Service Users when implementing the necessary actions. However the Organisation are committed Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 11 to redeveloping these plans following the principles of Person Centred Planning. At this stage the home are awaiting the new paperwork, which will support this new method of Careplanning. It has been agreed that it will take at least twelve months to complete this important and extensive piece of work; in the interim it is recommended the Individual Support Plans be updated to reflect the personal preferences of Service Users when implementing care. Risk assessments are in place to support Service Users to maintain their levels of independence safely. These were found to be reflective of review and contained detailed actions to be taken to support the Service User. All assessments contained in the Careplans were found to be up-to-date and reflective of review. Service Users are supported throughout their daily lives at the home, there is an open and honest dialogue between Service Users and Staff, ensuring Service Users have the opportunity to express their views and choices. As some of the Service Users have verbal communication difficulties other methods of communication are used throughout the home to ensure the wishes and personal preferences of the individual are acknowledged. Any restrictions in the choices made by a Service User are clearly reflected in the Careplan after assessments have taken place. Generally feedback from Service User, Family and Professionals comment cards received prior to inspection expressed satisfaction the care provision at the home, there was issues raised with the staffing levels of the home which are discussed further in the Staffing Standards of this report. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 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): 12, 13, 15, 16 & 17. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. A variety of enjoyable activities are provided to Service Users, which are in line with the needs and wishes of Service Users. Visitors are welcomed at the home ensuring Service Users are able to maintain their links with family and friends. Meals provided at the home are balanced and varied, ensuring the nutritional needs of Service Users are met. EVIDENCE: The home provides a variety of activities both internally and external to the home. The lounge area of the home is split into two areas with one providing comfy seating, T.V. and HI FI equipment and the other providing a sensory area for Service Users. This is a good use of space and supports the more dependent of the Service Users to interact with others in the home. The Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 13 sensory area has been earmarked for redecoration and modernisation to further support the Service Users. All Service Users attend day centred most days of the week with a home day provided, during this 1:1 time is implemented. The staff and management team are proactive in sourcing new activities and things of interest for Service Users to participate in. All routines and activities of the home promote independence, individual choice and freedom of movement. On the day of inspection the large majority of the Service Users were at day centre, returning in the early afternoon to a cheerful and warm welcome from staff. Activities were organised with equipment provided for Service Users to enjoy whilst the staff ensured the hygiene routines were implemented. There was an inclusive and relaxed culture with all Service Users needs met by a knowledgeable and experienced staff team. Service Users are supported to maintain their links with family and friends with all visitors welcomed to the home in line with the wishes of the Service Users. Any constraints on visiting are clearly documented and are only undertaken after consultation with relevant parties. Families are given the opportunity to be actively involved in the daily routines of the home and report feeling supported by the homes staff. There is an open dialogue between the staff and family members, which has provided a positive culture when dealing with sensitive issues. The homes staff undertake the cooking of the meals offered to Service Users, menus are well balanced and varied, taking into consideration the individual needs, and likes and dislikes of Service Users. Meals are unhurried with support offered where required. The communal dining/kitchen area is comfy and homely providing a safe and pleasant environment for Service Users. Due to the specialist needs of Service Users staff have their meals after Service Users needs have been met to ensure the unhurried and relaxed environment is maintained, this system is well organised with evidence of good practice observed throughout the meal time. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 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, 19 & 20. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The changing and ongoing healthcare needs of Service Users are met through a variety of professional therapists who with the staff team support Service Users. Care is implemented in a sensitive and respectful manner, which ensures the privacy, and dignity of Service Users is maintained. Robust medication systems are in place, which protect Service Users from harm. EVIDENCE: All Service Users are registered with a local G.P. service. The home also uses the services of specialist therapists such as District Nurses, Speech & Language Therapist, Physiotherapist, Occupational Therapist, Psychiatric consultant and an Epilepsy Consultant. In addition Service Users are registered with the Community Dentist and an Optician who will visit Service Users at the home. The Endoscopy Department at the local hospital is also involved with the maintenance of care for those Service Users using Peg Feeds. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 15 The G.P. reviews medication and is proactive in visiting Service Users in their home for consultation and reviews. All additional support is documented in the individuals Careplan this includes medical reports to ensure a consistent approach to meeting the healthcare needs of Service Users is maintained. Where possible all consideration is given to ensure gender appropriate care is offered to Service Users, should an opposite gender Carer have to undertake any duties this is done in a sensitive manner with systems in place which protect both the Service User and the Staff member. There are currently two male Service Users residing at the home, which has been taken into consideration when recruiting new staff. The Manager is proactive in ensuring the gender appropriate care philosophy is discussed with Service Users or significant others to ensure the wishes of Service Users are taken into consideration at all times. The attention and planning given to providing appropriate gender care in a balanced and sensitive manner is a positive example of the home meeting the equality and diversity needs of Service Users. All care is implemented in a sensitive and respectful manner ensuring the privacy and dignity of Service Users is maintained. Observations of staff on the day of inspection were positive with staff knocking on doors before entering and ensuring doors were closed to bathrooms and toilets. Staff demonstrated a clear understanding of the needs of the Service Users and undertook their duties in a professional manner ensuring they communicated with Service Users throughout any task. Service Users observed throughout the inspection appeared comfortable with the staff and happy and well cared for with their individual needs met within reasonable timescales. As the Service Users at the home are predominantly non verbal alternative communication systems have been put in place, staff are knowledgeable on the communication needs of the Service Users and ensure any gestures or noises are acted upon in a consistent and professional manner. Service Users who are able to communicate verbally expressed their happiness with the Staff, and satisfaction with the care and support received. The home operates robust medication systems, which are supported by the Organisations policies, procedures and training programmes. There were no gaps evident of MAR (medication administration records) with all entries appropriately signed. The contracted Pharmacist regularly inspects medication systems with an inspection having taken place on the same week as this inspection. Positive feedback has been received as a result of the Pharmacy inspection, which will support the home to further improve on its systems. It is recommended as a result of the Pharmacy inspection a risk assessment for the Controlled Drugs Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 16 facility, which is reflective of review, is formulated. Any outcomes of this risk assessment need to be actioned as soon as is reasonably practicable to ensure the ongoing protection of Service Users. The home are reminded to ensure any handwritten entries on MAR sheets are double signed and a copy of the prescription is faxed to the home to ensure it is available for auditing purposes. There were no out of date medications held in the home with the dates of opening written on all creams, ointments and liquid vessels. None of the Service Users presently self medicate, however two Service Users are supported to sign that they have received their medication, these records were found to be up-to-date and were also reflected on the homes MAR sheets. A record of the temperature of the medication cupboard is maintained daily. All staff have been trained to use the MDS (monitored Dosage System) currently being used at the home. One member of staff is responsible for the safe ordering and return of all medication with records maintained to provide a clear audit trail. Cotswold Cottage DS0000022965.V304077.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The Home operates the Organisations Feedback policy, ensuring all Service Users and significant others are supported to make a complaint appropriately. Policies and procedures are in place, which protect Service Users from Abuse. EVIDENCE: The Organisation operates a complaints policy known as the Freemantle Feedback, this provides the service with a recording form, a policy in both written and picture format and guidance on its use. There have been no formal complaints received at the home in the past 12 months. A copy of the policy is given to all parents and significant others and is available as part of the admissions pack. Additional copies are available in the home, which are easily accessed. A Complaints, Concerns and Compliments file is in place. The home has recently obtained the most up to date policy for the protection of vulnerable adults known as the Buckinghamshire Inter Agency Safeguarding Vulnerable Adults from Abuse Policy. The Manager is a POVA (Protection of Vulnerable Adults) facilitator, ensuring her staff team receive regularly updated training. All staff members have received POVA training with the new staff booked to attend courses. There are no outstanding POVA issues at the home, with all staff knowledgeable of the Counties reporting procedures should an allegation be made. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The environment at Cotswold Cottage is maintained to a high standard providing a safe, homely and pleasant environment for Service Users to enjoy. EVIDENCE: Cotswold cottage is a purpose built home for Service Users with Learning and Physical Disabilities. The home is a two-storey building providing large and comfortable single accommodation bedrooms. The home is pleasantly decorated to a high standard, providing a safe and homely environment for Service Users to enjoy. There are large communal spaces available with adaptations and equipment in place to further support Service Users. The home is maintained to a high standard with the day-to-day cleaning regimes undertaken by Care staff, the home was found to be cleaned to a high standard on the day of inspection with no offensive odours present. The Organisation operates a rolling programme to ensure the upkeep of the home, with a budget set aside for refurbishment and decoration to be used as Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 19 needed. The Manager has control over the purchase of smaller items for the home, with more costly orders put through the estates team for authorisation. There were no issues of concern with the environment observed on the day of inspection that would have an adverse affect on the Service Users. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The Organisation operates robust recruitment procedures, which maintains the ongoing protection of Service Users. There are suitable numbers of skilled and experienced staff that undertake regular training to support Service Users. EVIDENCE: The Organisation has robust systems in place for the recruitment of new staff. All potential staff submit applications for CRB (Criminal Record Bureau) disclosures prior to a start date. The files of six new staff were assessed at the time of inspection, all were found to be maintained to a high standard with no issues of concern. Staff do not work with Service Users prior to the return of the completed disclosure, however staff do begin their induction once a POVA 1st has been received, this system is well managed at the home with five staff receiving their full disclosure and one staff currently undertaking office duties with a POVA 1st. Two references are held on file for all staff prior to commencement of employment. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 21 The home hold copies of all relevant recruitment information with a checklist maintained in each file to ensure all security checks and other relevant information has been obtained prior to the start of employment. The home has a training and development plan in place, which supports staff to professionally develop and meet the needs of Service Users. All contracted staff are presently up-to-date with their mandatory training, with a new strategy in place to support relief workers to attend this training out of usual office working hours. All new staff have been booked to attend mandatory training. In addition to the mandatory training other courses have been attended by staff in the past 12 months, these include Registered Managers Award, Recruitment, PCP Facilitators, Sensory Communication, Disciplinary Process, Fire Risk Assessment, Rectal Diazepam and Epilepsy, Moving & Handling Assessors, Cultural Awareness, Hygiene, Passive Movements and Health & Safety Rep training. The Manager reported a strong commitment from her staff team to attend training, which is evidenced by the wide variety of courses attended by a large number of staff. The home ensures staffing numbers are maintained at a level that will meet the ongoing and changing needs of Service Users, the recent recruitment of a new Deputy Manager has been a positive step for the home in providing additional support to the Manager and Staff team. There are presently 70 vacant hours available to the home for recruitment, however not all of these will be filled to ensure the home is able to retain its valued and much needed relief staff. This is a positive use of vacant hours which ensures staff are available at times that are required by the Service Users such as early evening and for supporting the Service Users to access activities outside of the home. The home currently is relying on minimal support from Agency Staff with a maximum of 2 shifts per week covered by Agency workers. All Agency staff are familiar with the needs of the Service Users. Issues of concern were raised through feedback comment cards in relation to the vacancy levels at the home and the high usage of Agency Staff, it is hoped now the recruitment process has been completed for six new members of staff these valid observations and the impact of staff shortages will have been resolved. The Commission is satisfied the Manager is monitoring staffing levels and it will be left in her capable hands to ensure the home continues to be staffed by suitably skilled and experienced staff. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 22 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, 39 & 42. Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home is managed by a suitably skilled and experienced Manager who ensures the home operates safely and in line with the needs of the Service Users. The Organisation has robust quality audit systems, which support the improvement plan for the home, thus providing a safe and well run service for Service Users. The home has robust systems in place, which protect the health, welfare and safety of the Service Users. EVIDENCE: The home is managed by a suitably skilled and experienced Manager who oversees the day-to-day management of the home. She is currently working towards her RMA (Registered Managers Award) and ensures she attends Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 23 regular training to support her professional development. A new Deputy Manager has been employed since the last inspection; he is currently supporting the manager with office duties and completing his Induction whilst awaiting the return of his CRB. The home is safely managed taking into consideration the views of Service Users when planning any change in the home. There is an open and inclusive culture evident at the home with Service Users benefiting from a relaxed and professional service supported by staff and management. The Organisation has thorough quality audit systems in place, which are in line with the expected outcomes of the National Minimum Standards for Younger Adults. The home is due for its annual quality audit, which will take place in November 2006; the outcomes of this will provide the home with clear objectives for the coming year. Policies and procedures are regularly reviewed and distributed to the home. Service User and family questionnaires are regularly distributed to ensure their views are taken into consideration for planning any changes to the service. Monthly monitoring systems are in place to ensure the ongoing safety of the Service, which is submitted, to Senior Management for audit purposes. The home has clear systems in place, which protect the health, welfare and safety of Service Users. One member of staff overseas the systems in place at the home, she has undertaken additional Health & Safety Rep training to support her in this role. There were up-to-date records open to inspection for Fire safety, Infection Control and Generic Risk Assessments. Service Record and certificate dates were included in the pre-inspection questionnaire. There were no issues of concern raised in relation to health and safety with all requirements and recommendations from other agencies such as the Fire Authority and Environmental Health Inspections acted upon within reasonable timescales. Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X 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 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 It is recommended until the implementation of Person Centred Plans, the Individual Support Plans currently used are updated to reflect the personal preferences of Service Users when implementing care. A recommendation is made for the home to ensure a risk assessment is carried out on the storage facility currently used for the safe storage of Controlled Drugs. Any actions identified as a result of this risk assessment need to be put in place as soon as is reasonably practicable. 2. YA20 Cotswold Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford, OX4 2SU 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 Cottage DS0000022965.V304077.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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