Inspection on 09/05/06 for Cotswold Court

This inspection was carried out on 9th May 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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 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 Nick Jones Key Unannounced Inspection 9th May 2006 10:00 Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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 To be Appointed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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. 3rd December 2005 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 a Statement of Purpose and Service User Guide which is being adapted to an additional symbol-based version. The monthly fees charged by the home are £1351.35. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Key Inspection and was completed during one day and a morning the following week over a total period of 10 hours. Staff, including the manager, on duty were seen and spoken to individually. All of the service users were met and whilst their ability to offer comment, in the main, was limited it was evident that they were happy in the home and had a positive relationship with the staff. All staff were helpful and well informed during the inspection. One service user was away needing hospital treatment. A visit was also made to the local Stroud and District Mencap Society office to meet the Group Manager and Administration Manager. A number of records were seen at the home and they were generally well maintained and contained the required information. A tour of the home and garden was completed. The home was seen as comfortable and stimulating environment where staff are committed to meet the needs and wishes of the service users. What the service does well: Cotswold Court offers a very homely environment to the service users and the staff team work hard to make areas of the home suitable for the needs of the service users. The staff team has a good knowledge of the needs of service users and demonstrated they are committed to offering choice to service users, as much as possible. The staff team and management are to be commended for the staffing support they have been providing to a service user currently requiring hospital treatment. A good standard of home-cooked food is provided, with consideration to individual likes and dislikes. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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 Court DS0000016415.V291672.R01.S.doc Version 5.1 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 this service. The information provided by the home enables prospective service users/relatives/sponsors to make an informed choice. The home has an appropriate needs assessment policy and procedure that should ensure a potential service users’ aspirations and needs are assessed. EVIDENCE: The home’s needs assessment policy and procedure was viewed and found to indicate the home would conduct appropriate needs assessments which would include time spent with a potential service user in both their current circumstances and in Cotswold Court. There have been no admissions to the home during the previous 12 months. The acting manager stated he would be reviewing the homes’ Statement of Purpose and Service User Guide, which will include producing them in a symbol-based format. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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, and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of the service users are on the whole clearly identified and wherever possible met. The records of care plans and risk assessments of service users must be reviewed and updated to ensure consistency in staff support. Service users have been supported to make decisions and choices about their lives. EVIDENCE: Care plans were viewed in all the service users’ files. Three of these were viewed in more detail. Plans have been developed involving service users and key-workers. These were dated February and March 2005. Two of the plans have no record of any reviews of these plans since they were written. The Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 11 plans contain a good level of detail and are divided into sections that are easy to follow. All service users have had recent Individual Personal Planning meetings and these have produced goals and objectives. These meetings focus on activities and routines and can involve parents and staff from the day centre. The IPP goals and objectives should form part of the review of care plans and risk assessments. Observations of staff practice and discussions with them showed they have a good knowledge of the needs and routines of service users. Various risk assessments are in place in the individual files. Two of the service user files had not been reviewed and updated where necessary. Service users are supported to make decisions, and any limitations have been recorded or risk assessed where necessary. One service user has contact with an independent advocate. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ day time activities, social and leisure needs are identified and, on the whole, met. Insufficient staffing levels are sometimes affecting the frequency service users are able to access community facilities. Service users’ choice and freedom of movement are respected so promoting the rights of service users. The home provides meals which the service users enjoy and promotes their health and wellbeing. EVIDENCE: Each service user has a weekly programme and this indicated the activities, times and venues. Considerable care has been taken by staff to ensure the wishes and needs of the individuals are, wherever possible, met. The programmes include attendance at a day centre, college, and use of Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 13 community facilities. Service users also attend a social club in the evening during the week. One service user told the inspector that they enjoyed the things they did and that they are consulted over how they spend their time. They stated they liked going out on their own to Stonehouse and Stroud. Service users are supported to use a variety of community facilities. Records of this were viewed in community access and daily records. Staff described the range of activities they support service users with. The records and discussions with staff showed that the frequency of community activities has been adversely affected by staff shortages in recent months. Service users are offered holidays that meet their individual needs and wishes. This included a holiday in Cornwall and a visit to Spain. Social and family relationships are encouraged and supported and most service users have contact with family/friends. Daily notes viewed recorded the regularity of the visits. The rights of the service users are respected and the staff were seen to provide a flexible response to the varied needs of each service user. Service users are offered keys; one chooses to keep and use their keys. One service user requests staff lock their bedroom when not in the house. Staff place great emphasis on ensuring the food likes/dislikes of service users are known and responded to; service users are involved in menu planning as much as is possible. On the day of the inspection the tea consisted of lasagne and garlic bread. Staff had a clear understanding of the needs of service users at mealtimes. The menus provide a varied, nutritious and balanced diet. Mealtimes are seen as an important social occasion. Staff and service users sit together in the dining room for the main meals. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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, and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The support and guidance offered to service users by staff and health professionals ensure personal care and health care is adequately provided. Insufficient recording and regularity of health issues/checks could be putting service user’s health at risk. The procedures for the prescribing, storage and administration of medicines ensures the health and welfare of service users is maintained. EVIDENCE: Care plans detail the personal care and health care support needs of each service user. 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 a variety of health professionals. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 15 Some service user care plans stated that food and fluid intake should be monitored. Records being kept where not in sufficient enough detail to usefully monitor this intake in an accurate way. The manager and staff have been regularly visiting a service user in hospital over recent weeks and should be commended for their dedication in providing this support. Medication storage and administration were examined and were found to be satisfactory. There were some discontinued drugs being stored that should have been returned to the pharmacist. These had been prescribed for a service user who had required on-going hospital treatment. One service user selfmedicates and there were suitable risk assessments in place. One service user’s personal file contained a health professional’s assessment that stated their blood glucose levels should be tested twice weekly. Records viewed showed this was not taking place and gaps of up to two weeks between a record of a check were recorded. The manager stated this issue would be addressed to the staff team and would make a referral to the service user’s GP to ensure the service user received appropriate support for their diabetes. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ lives are improved and protected by staff that are focused on the needs of the individual. The home’s complaints procedure enables it to respond appropriately to concerns brought to their attention. Staff are aware of adult protection, however further training in ‘Whistleblowing’ procedures would be helpful. EVIDENCE: Evidence within this report indicates that staff listen and act upon the views and needs of service users. One service user stated they were able to talk to staff or the manager if they had any concerns. Staff receive training in Adult Protection; some staff were not aware of the ‘Whistleblowing’ policy and procedure. These are currently being reviewed and re-written. The staff team should be made aware of the completed policies and understand their role if needing to implement the policy. Several staff have undertaken “Total Communication” training which assists staff to respond to the views and wishes of the service users. The home has received an expression of concern from relatives of one service user regarding some aspects of their care. Minutes of a meeting held to discuss the concerns were viewed and showed the home was responding appropriately to these concerns. The records of service users financial affairs were viewed and were detailed and accurate. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 17 Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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, 26, 27, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean, hygenic and safe environment which meets the needs of service users. EVIDENCE: All areas of the home were viewed including all bedrooms. Décor and furnishings are of a good quality with bedrooms personalised to the tastes and preferences of service users. Fixtures and fittings were well maintained and appropriate to the needs of service users. The ground floor bathroom had recently been re-tiled. The hand-rail should be re-fixed. A stair lift has been installed which one service user chooses to use on some occasions. The manager stated the ground floor hallways are to be re-decorated, with white plastic scuff- boards being fitted to protect the walls from being damaged by wheelchairs. The home was clean and hygienic throughout on the days of the inspection. Staff have access to disposable gloves, aprons and laundry bags. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 19 The bathrooms are equipped with the required specialist equipment, offering bathing or showering facilities, and all were clean and well maintained. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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, 33, 34, 35, and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff who demonstrate committment and interest in providing the right care. Staffing shortages have significantly affected service users’ access to community facilities. A suitable recruitment process, on the whole, supports and safeguards service users. The training, development and supervision of staff ensures service users’ needs are met by a well trained and supervised staff team. EVIDENCE: Staff demonstrated over the course of the inspection that they are committed to meeting the needs of service users and are approachable and accessible to service users. There was good evidence that the home is well supported by other professionals such as clinicians from the Community Learning Disability Team. The home has only one staff with an NVQ 3. Two staff are undertaking their NVQ 2 in Care, and three are due to start in July. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 21 The home has had a relatively stable staff team since the previous inspection with two new staff commencing in post since that date. Staff absences are covered by staff from the home or staff from the other Stroud and District Mencap services. There was evidence from viewing daily notes, staff duty rotas and discussions with staff that service users’ access to community facilities has been affected by staff shortages. The home does not have access to locum/bank staff or agency staff. This was particularly evident on Wednesdays and at weekends. Staff meetings take place approximately every two months and minutes are kept. Regular staff supervision was being provided by the acting manager. Staff stated they feel the management of the home is supportive and accessible. The records of staff recruitment were viewed and found to be generally following the appropriate processes and checks. However one staff commenced their post one week before receiving their POVAFirst check. Discussions took place with the manager confirming that the home must consult with the Commission before commencing any staff before they have received a satisfactory enhanced CRB clearance. The acting manager must clarify with the Commission the reasons for starting staff in post before a full CRB has been obtained, that all other required checks and evidence are in place and that a risk assessment has been completed stating the staff will be not working in an unsupervised capacity and who will be supervising them. It was confirmed that no staff should commence in post until a POVAFirst check has been received. Staff receive a variety of mandatory training and a structured induction. This was being co-ordinated by another manager from the group. Details of the training completed by staff was not immediately available to the acting manager. This should be available in the home to enable the manager and staff to plan their training needs. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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, and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from committed acting manager who promotes good care practices and a person centred service. An application to become the Registered Manager must be forwarded to the Commssion to confirm the position of the acting manager. Health and safety monitoring is taken seriously in the home to ensure service users live in a safe environment. There was one shortfall where some weekly fire alarm tests were not undertaken. Service user’s and their relative’s views and preferences inform the aims of the home and staff practice. The home does not have a formal quality assurance system to evidence some of their consultative work with service users and their relatives. EVIDENCE: Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 23 The manager has been in post since January 2006. He is an experienced manager who has completed a Diploma in Management and 2 units of an NVQ 4 in Care. He is registered to commence the Registered Manager’s Award with Stroud College. The Group Manager stated the position of the acting manager would be confirmed by the beginning of June 2006. An application to be registered with the Commission is being forwarded. Discussions with staff, observation of staff practice and viewing of records showed the home ensure service users’ individual wishes are considered and wherever possible met. The manager stated he will be discussing with his line manager an appropriate quality assurance/monitoring system to be used at the home. Health and safety aspects of service provision are being maintained and monitored. Records viewed included fire safety checks, fire drills, water temperatures and servicing of equipment. Fire safety equipment servicing and a fire safety officers visit took place in February 2006. The records of weekly fire safety checks showed that this has not always being completed. The manager stated he would be training other staff to ensure, in his absence, these checks are always completed. Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 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 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 X Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 12 and 15 Requirement Care plans and risk assessments must be regularly reviewed and updated if necessary Sufficient staff must be available to support service users in regular leisure activities outside of the home The regularity and recording of blood glucose levels must be completed as indicated by health assessments Timescale for action 31/07/06 2. YA33 18(1)(a) 30/09/06 3. YA19 12(1) and 13(4)(c) 30/06/06 4. YA19 4. YA34 The regularity and recording of food and fluid intake, as required in care plans, must be accurately maintained 12(1)(a)&19(1)(4)(5) The home must ensure that recruitment procedures are followed that comply with the regulations as described in this report. ( the requirement not met from the previous DS0000016415.V291672.R01.S.doc 12(1) and 13(4)(c) 30/06/06 30/06/06 Cotswold Court Version 5.1 Page 26 inspection 30/12/05 5. YA42 12(1)(a) 23(4)(c)(v) Fire alarm equipment must be tested and recorded on a weekly basis An application to become the Registered Manager must be forwarded by the acting manager to the Commission 30/06/06 6. YA37 9 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA23 YA24 YA35 Good Practice Recommendations Staff should receive information and details of the revised ‘Whistleblowing’ policy and procedure The hallway re-decoration and replacement of the handrail in the ground floor bathroom should be completed The up to date records of staff training should be available in the home Cotswold Court DS0000016415.V291672.R01.S.doc Version 5.1 Page 27 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.V291672.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!