Inspection on 25/11/05 for Cottage Farm

This inspection was carried out on 25th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cottage Farm 19/12/08

Cottage Farm 20/06/08

Cottage Farm 20/06/07

Cottage Farm 18/04/06

Cottage Farm 04/05/05

Cottage Farm 07/12/04

Cottage Farm 20/07/04

Cottage Farm 07/01/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Cottage Farm Southampton Road Hythe Hants SO45 5TA Lead Inspector Annie Billings Unannounced Inspection 25th November 2005 10:30 Cottage Farm DS0000012379.V267173.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 Cottage Farm DS0000012379.V267173.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. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cottage Farm Address Southampton Road Hythe Hants SO45 5TA 023 8084 0661 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) www.macintyrecharity.org MacIntyre Care Care Home 5 Category(ies) of Learning disability (5), Physical disability (5), registration, with number Sensory impairment (5) of places Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents in the category LD referred to above are not to be admitted under the age of 40 years 4th May 2005 Date of last inspection Brief Description of the Service: Cottage Farm is registered to provide accommodation to five younger adults with a learning disability, physical disability or sensory impairment, although the home currently accommodates three residents over the age of 65. The home is a large spacious bungalow in a semi-rural setting, on the outskirts of Hythe town centre and the New Forest. Accommodation is provided within individual rooms, with communal facilities including a large, comfortable sitting room, spacious kitchen / dining room, one assisted bathroom, walk in shower room, separate WC and utility room. At the front of the property is a large parking area, with the garden area at the rear mainly laid to lawn, with small shrubs, a patio area and an adjacent fruit orchard. MacIntyre Care provides a Day Support Service to service users living in the home, enabling 1:1 support to access community facilities, and individual activities. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.5 hours and was the second inspection of the year April 2005 to March 2006. Many of the core standards were inspected during the previous visit on the 4th May 2005, therefore referral to both reports will give a full overview of the service. The home has been without a registered manager since December 2004. A new manager was appointed in July, and is undergoing the process for registration. A tour of the premises took place and care and other records were inspected. The inspectors met all of the residents, and observed their interaction with staff, and comment cards were received from four relatives and all five residents with assistance from family or day care support workers. Additional information was also supplied within a pre-inspection questionnaire and discussions were held with three staff members. Ten issues were raised as a result of previous inspections, some outstanding since 2003. A subsequent meeting was held with the providers to discuss concerns over the delays in addressing these issues, and an action plan was put in place with agreed timescales. Although progress has been made in several areas, it is disappointing that some issues have not been fully complied with. A statutory requirement notice has been issued to ensure full compliance. What the service does well: What has improved since the last inspection? Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 6 A version of the residents’ contract has been developed on audio tape to those unable to read the typewritten format, although there is no evidence this has been distributed to residents. The manager agreed to do this. Good progress has been made in reviewing assessments and care plans, including specialist assessments to ensure that sensory needs of residents are identified and met. Person centred plans are being developed, in formats that suit each individual, although it is recognised this work may take some time to complete. One staff member in particular has been very proactive in producing plans in DVD format, largely in their own time and using their own equipment. All staff have completed training in the safe handling of medication and sensory awareness, and other courses have been undertaken. A new assisted bath has been installed, and uncovered hot water pipes have been covered, and cleanliness throughout the home has improved. Residents’ files are more organised, although still contain a lot of duplication in recording. What they could do better: Assessment and care planning reviews must continue to ensure that residents’ changing needs and objectives are supported. Feedback from residents and relatives suggest they are unaware of the complaints procedure. Action must be taken to ensure that this process is accessible to all, and that people feel able to use it. Staff recruitment files must contain details of checks undertaken prior to employment, to ensure the safety of residents. Mandatory training updates and specialist training must be delivered promptly to ensure that staff have the appropriate skills to meet the residents needs. A quality assurance system must be developed to survey and obtain the views of residents, staff, relatives and visiting professionals. Improved systems must be implemented to ensure the health, safety and welfare of staff and residents. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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 Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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, 5 Specialist assessments and referrals to other professionals have been made, and other assessments are being reviewed, although these must be completed to ensure that all residents’ needs are identified. A version of the residents’ contract has been produced in audio format, although this has yet to be distributed. EVIDENCE: Sampling of three files showed that referrals have been made to specialists for assessment, particularly with regard to peoples’ sensory needs and the home have involved the community learning disability team to identify appropriate activities and interactions with staff. Not all of these are in place yet, but good progress has been made. Further work is necessary to ensure that all residents’ needs and aspirations are identified. This will continue to be monitored at future inspections. Detailed risk assessments are in place in some files, but other evidence within files suggests some need to be updated to ensure their relevancy i.e. One resident is identified at high risk of choking, but a more recent assessment contradicts this and states that the risk is minor. Another was in respect of use of cleaning products, yet the resident would be unable to use these products without the support of staff. One assessment identified that the resident can on occasions display challenging behaviour. The action to be taken to minimise risk states ‘all staff to be aware’, but gave no details of how this should be done or what to do next. A risk assessment for self-injury states, ‘Royal Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 10 National Institute for the Blind training if required’, but there is no evidence to suggest that the need for this has been assessed. The manager said that all risk assessments are currently being reviewed. Each resident has a copy of their written contract within their own room. It is difficult to ascertain their understanding of these documents, due to their disability, although the manager said that link-workers provide support to go through these documents. Due to some residents’ sensory loss, the home was asked to develop this document in formats that meet individuals’ needs. A version has since been produced on audio tape, although there was no evidence that this had been distributed. The manager agreed to do more work on this. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 Progress has been made in the development of care plans, and work is ongoing to ensure these are person centred, and in a format suitable for each individual. Appropriate support is given to ensure that residents’ have choices and made decisions about their lives. EVIDENCE: Since the last inspection, residents’ files have been indexed and reorganised to ensure they remain current, although a lot of information is still duplicated, and could be simplified. The “How I Like to be Supported” document alone is 30 pages long, much of the information is available elsewhere in the file, and is of little relevance to the resident to encourage ownership of their plans. Person centred plans are being developed, and some good work has been undertaken, although not all demonstrate that residents are at the centre of these plans, as some have no circles of support identified or dreams and aspirations reflected. One communication care plan states the resident communicates through gestures and body language, but gives no detail. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 12 These issues were discussed in depth with the manager, who advised of work being undertaken to address this, and demonstrated a good awareness of areas that need to be improved. One member of staff in particular has undertaken some innovative work in their own time, in producing a person centred plan in DVD format. This was viewed by the inspectors, and although not completed, demonstrates a good awareness of person centred planning (PCP), and was relevant to the resident. The manager advised that the member of staff is keen to develop this format, although the manager is aware this format will not be suitable to all. Action plans have been developed for each file, to ensure that progress continues, and specialist assessment outcomes are integrated into care plans once these have been completed. Interim detailed guidance has been put in place to identify to staff the support each resident requires from the time they get up to retiring at night, although individual support plans must be reviewed on a regular basis. One eating and drinking care plan has not been reviewed since September 2004. The appropriateness of “toileting programmes” for two residents was also discussed, as both residents are over 65. The manager advised they were working closely with the community incontinence nurse in respect of both residents involved. Evidence seen during the inspection confirms that staff have a good understanding of peoples needs, and indications are that good progress is being made in developing PCP’s. This work must continue, although it is recognised this may take time to complete. Development in this area will continue to be monitored at future inspections, with completion of all plans by an agreed timescale of 1st June 2006. Support staff were observed offering residents choices and enabling them to make decisions about their daily life. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15, 16 Activities are well-managed and contact with family and friends is encouraged. Routines within the home are changing in recognition of individual rights and responsibilities. EVIDENCE: In consultation with the community learning disability team and following recent communication training, a staff member advised that each participant on the course had to undertake a project with a chosen resident. As a result, and taking into account the residents interest in horse riding, a sensory collage of a horse was made, using real horsehair and leather, and plans to display the collage were discussed, as it is currently kept in the office. The inspectors were also advised of audio storybooks being borrowed from the local library. Other suggestions made in recent assessments are to be incorporated into care plans, once training has been completed. Recording of activities and measurement against objectives set by care plans has improved, and evidence was available to support that objectives set are being met. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 14 The manager and staff spoken with are keen for this motivation to be encouraged and continued. Additional one to one day services support is provided for each resident to facilitate a wide range of activities, and up to date information is now displayed on the notice board, to advise of community events and activities. One resident stated they receive regular visits from a relative, and would like to contact other relatives. Another stated they had visited their relative yesterday, with the support of another relative. Family contact for other residents is well documented, although not yet developed into circles of support. The manager advised that routines within the home are beginning to change, to reflect each individual’s rights and responsibilities, and to promote independence. This followed discussion around one resident’s routine that states the resident should be woken once their bath had been prepared rather than being encouraged to run their own bath. Routines observed around the home appeared flexible, with residents seen to come and go with community support workers, throughout the inspection. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Residents’ personal care, physical and health care needs are generally well supported, although the home needs to ensure that laxatives are administered only on GP instructions. Wishes and preferences are well documented. EVIDENCE: Feedback from relatives and residents was positive in relation to care and support. Relatives comments included, “very well cared for, and the carers are lovely kind people”, and “we are very happy with the care and attention”. Residents confirmed they like living at Cottage Farm, and feel they are well cared for, that staff treat them well and listen to them. Detailed guidance to staff concerning residents’ morning and evening routines have recently been put in place. Preferences, likes and dislikes and health care visits are well documented, although the need to ensure outcomes of visits are recorded has been encouraged. Training records seen demonstrate that all staff have now received training in the safe administration of medication, to meet a requirement of previous inspections. Sampling of residents’ files identified one resident with mental health needs, and two with incontinence. Staff have not received appropriate training, and this has been dealt with under standard 35. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 16 One file identified that a laxative chocolate was given to one resident on alternative days. There was no evidence to demonstrate this was on GP instructions, and the manager agreed to consult the GP, before continuing this practice. Support staff were observed offering appropriate, caring support where necessary. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 A satisfactory complaints procedure is in place, but the service must ensure this process is accessible to residents and relatives, and that they feel able to use it. Appropriate systems are in place to ensure that residents are protected from abuse. EVIDENCE: Observation during the inspection indicated that staff are aware of residents’ behaviour if they are unhappy, or in pain. However, three residents indicated they are unsure who to talk to if they are unhappy but residents confirmed they like living at Cottage Farm. The residents indicated that they feel they are well cared for, that staff treat them well and listen to them. Feedback from three of four relatives’ comment cards received indicated they are not aware of the complaints procedure. There is a satisfactory complaints procedure, and a pictorial version has been developed, which is displayed in the kitchen/diner. The manager must ensure that this is accessible to residents and relatives, and that people feel able to use it. Discussion with staff and management confirmed an awareness of issues of abuse, and the reporting procedures within the home. Training records indicate that seven staff have attended formal training in the protection of vulnerable adults following a recommendation at the last inspection. This needs to continue, to ensure that all staff have a good awareness of abuse issues. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Residents benefit from living in a clean, homely and safe environment, although shortfalls identified need to be addressed to ensure the home is well presented and ensure residents comfort. EVIDENCE: A tour of the premises was undertaken, and identified continued improvements in the overall cleanliness of the home. The manager advised that an expanded cleaning rota is to be implemented, to ensure this is maintained. A number of issues need to be addressed to ensure the home remains well presented and comfortable. A large stain was found on the lounge carpet. The manager agreed to ensure the carpet was cleaned. The lounge door to the patio could not be locked, although this received attention during the inspection. Nail holes in walls have been badly filled in corridor areas, which look unsightly, and the bathroom requires decoration, since the fitting of a new bath. A representative of the housing association, visiting during the inspection, advised that general decoration of the home is planned for early 2006, and it is hoped that the home will have had input regarding colours and textures from the sensory specialists, prior to decoration. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 19 Since the last inspection, hot water pipes have been boxed in, and new grab rails fitted in the WC. Polystyrene pipe lagging has been removed and replaced by carpet tiles on sharp corners of walls, to prevent harm coming to one resident with sensory loss. The appropriateness of this interim measure will be assessed during the outstanding occupational and sensory therapist assessment. Referrals were made to Social Services in June, although some input has been received from other agencies. Decorating and garden equipment was securely stored away and a recent visit by environmental health identified no issues. Bedrooms viewed had all been personalised to suit the resident. One bedroom has a broken chest of drawers, and the bed itself was very unstable. Another divan bed base was badly ripped, and a new chair broken due to heavy use by the resident. These items must be repaired or replaced to ensure the comfort of residents. A requirement made at previous inspections requested the provision of a call alarm system, to allow staff to summon help in an emergency. This was discussed with the manager, who advised they were unaware of any situations where this had been a problem. The manager agreed to risk assess this area, to determine if a system needed to be implemented. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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): 33, 34, 35 Staff and residents are potentially at risk because some staff work long shifts and excessive hours. Additionally, the recruitment and training processes are insufficiently robust to protect residents and meet their needs. EVIDENCE: The home has a core staff team, that has worked with the residents for a number of years, and have built up good relationships. All five of the residents looked well cared for and settled. The staff rota sampled identified that two or three members of staff are on morning shift, two on afternoon shift with two overnight. From observation during the day, staffing was at an adequate level to meet service users’ needs, particularly in view of the additional day services support. Two staff members are on long-term leave, and an appropriate policy and procedure has been introduced to manage this. Relief hours are covered by the existing staff team, which has resulted in some staff working fourteen hour shifts and upwards of fifty hours per week on a regular basis. Although this has maintained staffing levels, the manager must ensure the health and safety of both staff and residents and has agreed to keep this under review. Interaction observed between staff and residents was appropriate, and demonstrated the close relationships built. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 21 Three staff files sampled were incomplete, and did not demonstrate that appropriate checks had been undertaken prior to employment. One of three contained an application form, all had proof of identity but no references or photographs were available nor was there confirmation of criminal records bureau checks having been undertaken. A requirement has been made to ensure that the required documentation is in place to demonstrate that all appropriate checks are undertaken prior to employment. Training records were sampled. These showed that some training had been undertaken since the last inspection, although shortfalls were still evident. All staff have now received training in medication, and sensory awareness. One staff member requires update training in food hygiene, two require first aid and three require moving and handling updates. Three staff have received training in challenging behaviour, five have completed communication training and three have undertaken training in infection control, although it is noted that a further course is booked for the 16th December. Fire training was undertaken by seven staff on the 19th May, and the manager gave assurances that all staff would receive ongoing training twice per year. There was no evidence that any of the current staff, other than the new manager, have received any training in mental health or continence training, although files stated that some residents had these needs. Although progress has been made, there are still gaps in staff training records, despite assurances being given within action plans from the provider. The registered provider must ensure that staff have the appropriate skills to meet residents needs, and that mandatory training is updated promptly. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The new manager is giving clear leadership and direction for the service, from which residents should benefit. New procedures are being implemented, but issues remain which need to be addressed to ensure the health, safety and welfare of residents. EVIDENCE: Staff spoken with said that the home is benefiting from its’ new leadership and direction, and practices within the home are changing to ensure the service is run for the benefit of residents. The manager has developed a service plan, to improve all systems and practices in the home, including health and safety. A requirement was made at previous inspections to develop a system of quality assurance to seek the views of residents, staff, relatives and visiting professionals. The manager said that the annual questionnaire was to be reviewed following a poor response of one questionnaire in March. No evidence was available to support this being done. The manager commented on the difficulties of evidencing resident involvement in decisions about the running of the service, when there are severe communications barriers. The inspectors Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 23 suggested the involvement of advocates or relatives to support those with communication difficulties. The requirement has again been repeated. An annual risk assessment of the premises was available, and monthly health and safety audits are undertaken to ensure the home is maintained well and safe working practice is undertaken. Risk assessments are currently being reviewed, to include residents individual risk assessments. Current maintenance certificates were available for equipment in the home. Fire safety equipment is serviced regularly, although internal checks are not completed regularly. Weekly fire alarm tests were not undertaken on the 12th September, 28th October or the 14th November. Extinguisher visual checks were not undertaken between 1/5/04 and 21/10/05. The manager gave assurances these would be kept up to date. Sampling of accident reports and incident audit book identified one incident of misadministration of drugs, and the inspector was advised of a further incident that day. The first incident had not been reported to the Commission under regulation 37, nor identified within the regulation 26 report dated the 22/11/05. The manager agreed to forward regulation 37 notices to the Commission, and advise of action taken to prevent reoccurrence. Consultation with the pharmacist to implement new procedures and an audit system is underway. The certificate of employer’s liability, displayed in the reception area, was out of date, and action was taken to address this during the inspection. Environmental health visited the home on the 18th November. No requirements were made, and one recommendation to monitor and record hot food temperatures has been addressed, although recording is intermittent. The shortfalls identified above, together with gaps in staff training, some staff working excessive hours and long shifts do not adequately ensure the health safety and welfare of staff and residents, although improvements and progress made have been clearly identified. Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 1 1 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cottage Farm Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X 1 X X 2 x DS0000012379.V267173.R01.S.doc Version 5.0 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA22 YA34 Regulation 22 19 Requirement Timescale for action 31/01/06 3. YA35 18(1)c The provider must ensure that the complaints policy and procedure is effective. All staff files must contain the 31/01/06 required documentation listed in Schedule 2 of The Care Homes Regulations 2001. The provider must ensure that 28/02/06 all staff are fully trained. This should include prompt delivery of core training updates, as well as specialist training in communication, behaviour management, mental health and continence to meet individuals’ needs. Timescale of 31.9.03, 1.12.03, 30.6.04, 31.10.04, 31.3.05, 1.7.05 not met, although progress has been made. The provider must ensure that the running of the home is informed by the views of service users and their representatives, staff, relatives and visiting professionals. Timescale of 31.8.03, 31.4.04, 31.3.05, 1.7.05 not met. 4. YA39 24 28/02/06 Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cottage Farm DS0000012379.V267173.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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