Inspection on 03/12/05 for Cotswold Court

This inspection was carried out on 3rd December 2005.

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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cotswold Court 13/06/07

Cotswold Court 09/05/06

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 Simon Massey Unannounced Inspection 3rd December 2005 10:30 Cotswold Court DS0000016415.V270758.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 Court DS0000016415.V270758.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 Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cotswold Court Address Browns Lane Stonehouse Glos GL10 2JZ 01453 825115 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 Ann Marie Case Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 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. 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 Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 3 hours on Saturday 3rd December 2005. The inspector spoke with two care staff, one of whom is a senior worker currently sharing the responsibility of managing the home. The inspector also met 5 of the 6 service users who live at the home. Records were examined including care plans, staff rotas, fire safety, medication records, staff files and daily recording. A brief inspection was also undertaken of the environment. This was the second visit to the home in the current inspection year and a more detailed report against the core national minimum standards can be found in the previous report. What the service does well: What has improved since the last inspection? What they could do better: The home needs to provide a period of stable and consistent management. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 6 The home needs to ensure that it understands and complies with the regulations regarding any incidents or issues that must be reported to the Commission. The home needs to ensure that its recruitment procedures comply with the regulations which helps ensure that service user are properly protected. 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 Court DS0000016415.V270758.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 Court DS0000016415.V270758.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): These standards were not inspected during this visit. EVIDENCE: There have been no admissions to the home during the previous 12 months. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9 The care planning system in place is appropriate to the needs of the service users. Staff support service users to make decisions and choices EVIDENCE: A sample of care plans were examined and these were detailed and being reviewed at appropriate intervals. The daily recording in personal files is somewhat brief, containing entries such as “care given” and “normal routine completed” and often gives no evidence of what service users have been doing for periods of time. Files give advice to key-workers as to how advocates can be accessed for service users and individual preferences are recorded in the plans. Service users were observed being supported to make decisions about their activities, with staff having the required communication skills and knowledge of the people concerned. All risk assessments were in place and up to date Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 10 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): 12,13,14 & 15 The home supports the service users to lead settled lifestyles that are based on their assessed needs and where possible their identified wishes and choices. EVIDENCE: It was evident that the staff team have continued to support service users to pursue their interests and maintain family contacts. Records showed a number of regular trips being organised and also events and activities being organised within the home. On the morning of this inspection two service users were due to visit their families and two more were being taken to another service user’s relatives to attend a birthday party. One person described how the staff had helped them to make their Xmas arrangements. One person went into the local community on their own, to attend a community social event. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 11 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&21 The home provides a good standard of personal care and support but needs to ensure that medication procedures are correctly followed for these standards to be met. EVIDENCE: Care plans detail the personal care that is required and staff do not undertake responsibilities in this area until appropriately trained. Health needs are being monitored and appointments and outcomes recorded. There is evidence of consultation with health professionals and the previous requirement of providing dental checks has been met. Where appropriate food and fluid intakes are monitored but an observation is made that some of these records could be more precise in measuring quantities. Medication storage and administration were examined and some errors were found in the recording of medication given. The senior support worker satisfactorily explained how she was dealing with this. Some of the homely remedies in the cabinet were not correctly labelled and this needs to be addressed. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 12 The inspector was informed of action taken against a staff member who had incorrectly administered medication. The Commission were not informed of these errors or the subsequent action taken by the home. These omissions are the subject of requirements made in this report. The home is yet to complete the bereavement forms that are contained in the individual files and this requirement is therefore repeated. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 13 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): These standards were not inspected during this visit. EVIDENCE: Whilst these standard were not inspected in themselves, the home needs to comply with the requirements made against staff recruitment, medication administration and Regulation 37 Notifications for Standard 23 to met in the future. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29&30 The home provides a homely and well-maintained environment that meets the needs of the present group of service users. EVIDENCE: All communal areas and bedrooms were seen and all were well decorated and maintained. Individual rooms were personalised and staff have supported service users to decorate and arrange their rooms according to needs and personal taste. The accommodation is homely and comfortable. The home was clean and hygienic throughout on the morning of the inspection, though a requirement has been made to replace the flooring in the laundry that is damaged. The bathrooms are equipped with the required specialist equipment and all were clean and well maintained. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 15 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): 31,32,33&34 The staff team have worked well to maintain standards of care through another unsettled period for the home. A serious shortfall was identified in the recruitment procedures and the home needs to ensure that these issues are addressed if service users are to properly protected. EVIDENCE: On the morning of the inspection there were 2 staff on duty. One person was supported a group of people to attend a keep fit class, which is a regular Saturday morning activity and one staff member remained in the home with 2 other service users. The rotas showed that minimum staffing levels were being maintained, with the rota being organised to ensure that staff were available who were trained to administer medication. The home has provided accredited training in this area. The rota also records whether a driver is available. The senior staff member explained that during the staff shortages they ensure that, if required, staff from the other homes in the organisation can be provided to supervise the administering of medication. These staff are familiar with the home and the service users. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 16 One staff member stated that the support and input from the senior staff provided from the another home during the absence of the manager, had helped ensure that the standard of care provided had been maintained. Staff on duty demonstrated a good professional awareness of their roles and the needs of the service users. The home has recently started a new staff member but the correct recruitment procedures have not been followed. The staff file contained no references, though these have been sent for, the application form was incomplete in that it did not contain a full employment history, and the home were yet to receive a CRB disclosure or receive a POVA clearance. The senior support worker from a Supported Living set up run by the organisation, had been responsible for the recruitment but had not been given sufficient guidance on the required procedures under the regulations. In the absence of the registered manager the organisation must take responsibility for recruitment and ensure that staff responsible are aware of the procedures to be followed. The new staff member is not working unsupervised and is not permitted to undertake personal care tasks but should not have commenced work without the checks being completed. Any flexibility around the recruitment procedures needs to be agreed with the Commission and recorded. The senior support worker undertook to check the references by telephone and provide a full employment history from the staff member. They agreed to liaise with the registered manager (who was returning to work the following Monday) and the organisations business manager. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 17 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&42 Serious shortfalls were identified in the management of the home in regard to staff recruitment and notifications to the Commission. The senior staff covering the home in the absence of the manager have worked hard to ensure staff are supported and positive outcomes have been maintained for service users. EVIDENCE: The registered manager has been absent from the home since September but was due to return to the home the Monday following the inspection. The Responsible Individual has kept the Commission informed of the management arrangements for the home. A new manager is due to take up the post in January 2006. The organisation are required to inform the Commission in writing of the intended changes and permanent arrangements. The senior staff drafted in to cover the home are to be commended for the standard of care they have strived to maintain and the requirements made against the management standards are not a reflection upon their abilities or commitment. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 18 Disciplinary action was recently taken against a member of staff, who has now moved to another position within the organisation. The Commission were not informed about this and a requirement has been made that details are supplied. The organisation must ensure that it is aware of the requirements of Regulation 37 and that all notifiable incidents are reported. The registered manager and those staff with management responsibilities within the home should also be made aware their responsibility under this regulation. All fire safety checks and maintenance have been completed and recorded and all potentially hazardous materials are correctly stored. Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 19 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 X X X X X Standard No 22 23 Score X x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 1 X x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cotswold Court Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 x DS0000016415.V270758.R01.S.doc Version 5.0 Page 20 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 YA37 Regulation 8(1)&38 Requirement Timescale for action 30/12/05 2 YA37 3 YA34 4. YA21 5 YA30 The organisation must inform the Commission in writing of the intended management arrangements to be put in place in the home 12(1)(a)&37 The home must ensure that the Commission receives Reg 37 notifications in relation to events in the home. This must include medication errors and staff disciplinaries 12(1)(a)&19(1)(4)(5) The home must ensure that recruitment procedures are followed that comply with the regulations 12(3) The home should complete the bereavement questionnaires in the individual files(requirement not met from previous inspection 31/08/05) 13(3) The home must replace the flooring in the laundry room in line with DS0000016415.V270758.R01.S.doc 30/12/05 30/12/05 31/03/06 31/01/06 Cotswold Court Version 5.0 Page 21 standard 30.4 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 YA19 Good Practice Recommendations The home should consider whether the recording of fluid and food intakes needs to be more precise and quantifiable Cotswold Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Court DS0000016415.V270758.R01.S.doc Version 5.0 Page 23 - 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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