Inspection on 13/06/07 for Cotswold Court

This inspection was carried out on 13th June 2007.

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 Court 09/05/06

Cotswold Court 03/12/05

Cotswold Court 07/06/05

Cotswold Court 21/12/04

Cotswold Court 22/07/04

Cotswold Court 15/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Cotswold Court Browns Lane Stonehouse Glos GL10 2JZ Lead Inspector Mr Paul Chapman Unannounced Inspection 13 and 27th June 2007 09:00 th DS0000016415.V336608.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 DS0000016415.V336608.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. DS0000016415.V336608.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotswold Court Address Browns Lane Stonehouse Glos GL10 2JZ 01453 828275 01453 756192 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) Stroud & District Mencap Homes Foundation Limited Mrs Annette Case Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000016415.V336608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 LD(E) placed for named service user within total registered numbers. This condition to be removed once the service user is no longer accommodated. 9th May 2006 Date of last inspection Brief Description of the Service: Cotswold Court is a residential care home for six adults with learning disabilities. The home is situated on the outskirts of the town of Stonehouse and is set in large grounds that it shares with another house. This other house provides supported tenancies for adults with learning disabilities and was formally a registered home. Both these properties are owned and maintained by the Stroud and District Mencap Society. The house provides spacious and homely accommodation, with all single bedrooms having en-suite facilities. The home provides twenty-four hour staffing and is well situated to access local facilities and amenities. The home has symbol-based versions of the Statement of Purpose and Service User Guide. The weekly fees for living in the home range from £519. 20 to £604. 69. DS0000016415.V336608.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection site visit was completed over two days. On the first day of the site visit a number of people were on holiday supported by the staff. The inspector completed a tour of the premises with the registered manager; spoke to staff and people that were at home. The care of three people was looked at in depth. This included looking at their financial, medication and personal records. On the second day of the site visit seven staff were interviewed about the care they provide. Other records examined included staff files, training, health and safety information and quality assurance records. Four people living in the home were spoken to about what it was like to live there and the inspector spent time in the home’s dining room observing staff interactions with people. What the service does well: The home assesses people’s needs before they move into the home to minimise the risk of their needs not being met. The assessment process involves people visiting the home and assessments being gathered from other relevant professionals. Speaking with the last person admitted to the home they were satisfied with the assessment/admission procedure. Care plans provide staff with detailed information about people’s needs and the steps they need to take meet those needs and wishes. These plans are regularly reviewed and risk assessments are in place to minimise potential risks. People lead active lifestyles supported by the staff team. People said that there were enough thinks to do and that they enjoyed living in the home. The home has developed a system using symbols and pictures that enables people to choose what they would like to eat. People living in the home said that they have a good choice of food and that it was nice. The home is comfortable, homely and clean. Staff receive regular training to meet the needs of the people living in the home. DS0000016415.V336608.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The new life plans should be implemented for all of the people living in the home. The manager should make this a priority goal. Risk assessments should be linked to care plans where appropriate to ensure that all staff read risk assessments associated when meeting people’s needs. Staff supporting people to attend doctor’s appointments should be knowledgeable about the person’s needs and the reason for the appointment. 2 staff should sign all financial transactions. The home should complete assessments of people’s capacity to manage their own finances. A quality assurance system needs to be developed to allow the manager to monitor outcomes for people and address shortfalls. DS0000016415.V336608.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000016415.V336608.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 DS0000016415.V336608.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home does not admit people to the home whose needs cannot be met therefore people are not put at risk unnecessarily. New residency agreements have been produced with pictures/symbols to enable people with communication difficulties to understand them more easily. EVIDENCE: On the day before this unannounced site visit the home admitted a new resident. As part of the inspection this admission process was examined in detail. Whilst examining the person’s file a completed needs assessment was seen. This had been completed by a social worker and forms the basis for developing care plans. Staff had written detailed notes about what they found when the person visited the home before they moved in. Notes showed that they had come for tea, a day and an overnight stay. Notes provided the manager with supporting evidence to be considered as part of the assessment. Once the manager had decided that the home could meet the person’s needs they wrote to them confirming this. DS0000016415.V336608.R01.S.doc Version 5.2 Page 10 The inspector spoke to the person about the admission process. They stated that they had found the process to meet their needs. They confirmed that they had visited the home before they moved in and felt they were listened too. The person stated “I like it here and I am starting to feel a bit more settled”. On the second day of the inspection two weeks later the person stated, “I’m really glad that I moved”. From the information seen by the inspector and the comments made by the person admitted to the home this admission process appears to have been well managed and provided the person with a good outcome that meets their needs. Residency agreements are being reviewed at present. The new version seen in one file makes use of pictures and symbols to enable people with communication difficulties to use them more easily. DS0000016415.V336608.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have detailed care plans that are reviewed regularly and enable staff to meet peoples needs consistently. People are empowered to be involved in the day-to-day running of the home. People are not put at unnecessary risks due to the detailed risk assessments that are in place. EVIDENCE: A requirement of the previous inspection report was that the manager must ensure that care plans and risks assessments must be regularly reviewed and updated. The files examined showed that this is now happening. Each person living in the home has a key worker. DS0000016415.V336608.R01.S.doc Version 5.2 Page 12 Three files were examined in detail. The files for two people that had lived at the home for a long period of time showed that comprehensive care plans had been developed covering many aspects of their lives. Examples of these areas include plans for social interaction, communication, sleeping, mobility and eating and drinking. The level of detail present in the plans seen was good and enabled staff to be consistent in the manner they supported people to meet their needs. The third file to be examined was that of the person who had recently moved in. This showed the manager was in the process of developing care plans for different areas of the person’s life based on the needs assessment and from gathering information since they moved into the home. Examining the review process for people’s care plans the manager must ensure that sufficient detail is recorded by staff, some reviews provided limited information. Whilst completing the site visit the inspector spoke to the group manager who explained that the organisation are going to implement a new “life plan” document with each person. This will be person centred and when completed will provide a detailed overview of the person and the things that are important them. On the first day of the site visit the majority of people that live in the home were on holiday supported by the staff. The inspector returned two weeks later to speak with more of the people living in the home. Two people spoke about being able to make choices and decisions, whilst throughout the site visit the inspector witnessed numerous occasions where staff supported people to make their own decisions and choices. Conversations with staff showed that they were led by the needs of the people living in the home. Speaking with staff and people living in the home, wherever possible people participate in the day-to-day running of the home. A good example of this is the menus where staff have developed a system of picture menus/recipes for meals that empowers people to make a choice where they may have found it difficult in the past. Detailed risk assessments were available in each of the files examined. These assessments were being reviewed regularly. A recommendation discussed with the manager is to “link” risk assessments to care plans were it is appropriate. All of the information about the people living in the home is stored securely. DS0000016415.V336608.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff support people living in the home to lead active lifestyles that are lead by their interests and hobbies. People are supported by staff to maintain relationships with their friends and families and they are welcome to visit when they wish. People are empowered to choose what they would like to eat by the system developed by staff. EVIDENCE: People lead active lifestyles and activities are available in and outside the home. Staff write daily notes and monthly summaries for each person that provide good evidence of activities being completed. Speaking to people living in the home and the staff they confirmed that activities include attending day services and college, going bowling, cinema, DS0000016415.V336608.R01.S.doc Version 5.2 Page 14 shopping, eating out, attending social clubs, going to the local leisure centre (water aerobics), music sessions, drama sessions, swimming and a qualified masseur visits regularly. In house people are supported by staff to complete craft activities, play football on the lawn, do recycling and other activities. People are supported by staff to visit and use the facilities in the surrounding towns of Stroud, Gloucester and Cheltenham. Staff make good use of photography to take pictures of activities they complete, this allows people to remember activities they have been involved in more easily. Staff had supported people to use chalks to create pictures and the photos showed them doing this. The staff are in the process of creating a photo board of various activities with people living in the home. At the time of the first site visit staff were supporting 2 people on holiday in a cottage in Somerset. At the 2nd site visit people spoke about this and how much they enjoyed it. Daily notes and comments from staff confirmed that people living in the home see their relatives regularly and staff support them to do this. The CSCI received one completed survey from a parent who stated that they were “very happy with the care provided by the home”. Staff have created a picture menu book to make it easier for people to choose what they would like to eat. The book provides a good selection of meals and snacks that people may like to choose from. Each Tuesday evening people meet to choose the menu for the following week. Staff sit with people and support them to go through the menu book. The daily menu shows which person chooses each meal. Staff record what people actually eat in daily notes. Once the meals have been chosen people are involved in shopping for the groceries with staff, and are also involved in preparing the meals. The process for choosing meals empowers people that may have communication difficulties through the use of pictures. This is a really good practice by the home. A recommendation of this report is that this could be further improved by creating a photo shopping list system. This was discussed with the manager and a staff member. When people living in the home were asked about the food they commented that they thought it was nice, and confirmed that they were able to choose what they liked. DS0000016415.V336608.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal care needs and preferences are appropriately met by staff having detailed care plans/guidelines to follow. People are protected by the medication administration within the home. EVIDENCE: Each of the files seen contained detailed care plans/guidelines for staff to follow when providing personal care for people. This ensures that people’s need are met consistently as they request. The previous inspection report made two requirements relating the recording around people’s health needs. It was required that the manager ensured peoples blood glucose levels monitored and recorded as identified in the health assessment and that food and fluid intake was recorded as identified in the care plan. Both of these areas were seen to have been addressed at this inspection. DS0000016415.V336608.R01.S.doc Version 5.2 Page 16 The files examined provided detailed notes of appointments with other professionals (e.g. doctors, dentists, chiropodists and opticians). The CSCI received a completed survey from a GP, they commented that sometimes people attend appointments with staff that do not know them well enough and this makes it difficult for the GP to work with the person. It is a recommendation of this inspection report that the manager addresses this. Medication administration was examined and was seen to be managed correctly on the whole. One minor shortfall was that one of the homely remedies had not been labelled with the date it was opened, this was brought to the attention of the manager. In the files examined peoples wishes relating to ageing and illness had been addressed appropriately. DS0000016415.V336608.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are able to make a complaint if they are unhappy and staff will support them to do this where it is appropriate. The records of income and expenditure for the people living in the home minimise the risk of people’s money being used inappropriately. EVIDENCE: The home has a complaints procedure and the files seen contained a copy of it. Speaking with people they were aware of the procedure and one person said that if they were unhappy they would speak to their key worker, or the manager. There have been no complaints to the manager or the CSCI since the previous inspection was completed. The home has a whistle-blowing policy and staff that were spoken with were clear as to the steps they would take if they witnessed poor practice from a colleague. There has been an incident recently where staff have used this policy and appropriate actions were taken as a result. The majority of people in the home are unable to manage their own finances and the manager and staff oversee this. Financial records were examined and DS0000016415.V336608.R01.S.doc Version 5.2 Page 18 showed that balances were correct at the time of this site visit. At the time of this inspection the person who had moved in recently wished to keep their money in their bedroom, but was unable to securely. Since the inspection was completed the manager has confirmed that all people now have a personal safe in their bedroom. Examination of the financial records showed that although the current system was effective it could be improved. It is recommended that the manager ensure that 2 members of staff sign all transactions and that they complete a financial management assessment to identify whether people have the capacity to manage their own finances. DS0000016415.V336608.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable and safe environment that meets their needs. EVIDENCE: As part of the site visit a tour of the premises inside and out was completed with the registered manager. To the front of the property is a good-sized lawn that people living in the home use for activities (football and other things). To the rear of the property is a yard. The tour of the premises also showed it to be clean and hygienic throughout. People living at the home said that it was always “clean and tidy” and that they were responsible for cleaning their bedroom. Staff sign a form at the end of a shift confirming what chores have been completed. The building provides people with a separate lounge and dining room with sufficient space to meet the needs of the people that are currently living there. DS0000016415.V336608.R01.S.doc Version 5.2 Page 20 Both of these rooms are decorated to good standard and furnished with a range of furniture and personalised with people’s belongings. The kitchen is due to be re-furbished. Each of the bedrooms were seen. All of the bedrooms were decorated to a good standard and appeared to reflect the character/interests of the people they belonged too. All of the bedrooms have locks. The home provides specialist equipment to meet people’s needs and the equipment seen had been serviced by appropriately trained engineers. All of the toilets and bathrooms were seen and no issues were identified. DS0000016415.V336608.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from staff that are appropriately trained to meet their needs and this minimises potential risks. Thorough recruitment procedures ensure that people are not put at any unnecessary risks. Sufficient staff are employed and this ensures that people’s needs are met consistently. EVIDENCE: Seven of the staff were interviewed as part of the two site visits. All of the staff interviewed were clear about their role and responsibilities within the home. Each person was satisfied with the training they have received and gave examples of completing induction, NVQ (National Vocational Qualifications) in care, medication administration, food hygiene, first aid, fire safety, manual handling and infection control. All of the staff said that they had regular supervision. Two of the people living in the home made comments that “the staff are nice and it’s good living here”. DS0000016415.V336608.R01.S.doc Version 5.2 Page 22 Staff stated there were sufficient staff available to cover shifts adequately. Staff rotas were examined and showed that the home was staff 24 hours a day, 7 days a week and that there were 3 staff per shift and 1 staff member slept in. There is a picture rota on the dining room wall which enables people to know who is on duty for the next 24-hour period. Recruitment records for 2 of the staff were examined and showed that all of the documents required by the regulations were present. Staff supervision records confirmed that staff receive regular supervisions and appraisals have been completed. The manager is responsible for booking and recording completed training. Records of training were present for all of the staff and supported the comments made by them when interviewed. Since this inspection was completed the manager has confirmed that all of the staff training records are now up to date. DS0000016415.V336608.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 People who use the service experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from the approach of the manager who improved the team spirit. The staff team are motivated to providing a good quality service that is lead by the needs of people living in the home. Quality assurance must be developed further to provide continuous improvement in the home. A fire safety risk assessment must be completed so that people living in the home do not continue being put at unnecessary risks. EVIDENCE: Since the previous inspection was completed a new manager has been employed, they have recently completed their registration with the CSCI. DS0000016415.V336608.R01.S.doc Version 5.2 Page 24 The staff spoken with were very positive about the new manager’s input in the home so far. They made comments including “the staff team are more settled”, “they have had a positive effect on the people living in the home”, “the manager is understanding and supportive”, “there has been a big improvement since the new manager started”, “the manager is good to talk too”. Observations of the interactions between the staff, manager and people living in the home were respectful and positive. Both the staff and people living in the home were able to confirm this. Regulation 26 visits are completed as required by the provider. The home has developed a survey/questionnaire about the home that residents are asked to complete. Examples of these were seen. A discussion took place about the findings of this survey, and the manager must ensure that the findings are followed up with actions where they are required. It was also suggested to the manager that they should develop a system of assessing the quality of the service delivered, examples of this may include looking at the actual activities provided to people living in the home. The manager stated that the home’s policies are being reviewed and re-written currently. Health and safety around the home is well managed on the whole: • • • • • • Portable Appliance Testing was completed in May. Hot water outlet temperatures are tested monthly. A food probe is used to test temperatures of prepared meals. Fridge and freezer temperatures are tested daily. Chemicals used for cleaning are stored securely and data sheets are available. Qualified engineers service specialised equipment. Examination of records for fire safety equipment being checked by staff showed the following: • • • Emergency lighting had not been tested since January ’07. A fire drill had been completed in June ’07. Fire alarms had been tested weekly. At the time of the site visit the inspector highlighted the shortfall in testing the emergency lighting. Before this report was finalised the manager confirmed that this had been addressed. The inspector did not see a copy of the home’s fire risk assessment on this occasion. The manager confirmed that the home had one, and has now also completed another fire risk assessment document downloaded from the Fire Service website. This will be examined at the next site visit. DS0000016415.V336608.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 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 3 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 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 3 2 3 X 3 X DS0000016415.V336608.R01.S.doc Version 5.2 Page 26 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. 2. 3. 3. 4. 5. Refer to Standard YA6 YA9 YA19 YA23 YA23 YA39 Good Practice Recommendations The new life plans should be implemented for all of the people living in the home. The manager should make this a priority goal. Risk assessments should be linked to care plans where appropriate to ensure that all staff read risk assessments associated when meeting people’s needs. Staff supporting people to attend doctor’s appointments should be knowledgeable about the person’s needs and the reason for the appointment. 2 staff should sign all financial transactions. The capacity for people to manage their own finances should be completed. The home’s quality assurance system should be developed further by the manager. The quality assurance system should enable the manager to monitor and assess the quality of activities, food and care planning. DS0000016415.V336608.R01.S.doc Version 5.2 Page 27 6. YA39 The manager should ensure that if they use the quality assurance questionnaires/surveys with people living in the home that any issues brought up are addressed. DS0000016415.V336608.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000016415.V336608.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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