Inspection on 28/06/07 for Cotteridge House

This inspection was carried out on 28th June 2007.

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

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

Other inspections for this house

Cotteridge House 17/11/05

Cotteridge House 21/06/05

Cotteridge House 24/11/04

Cotteridge House 27/07/04

Cotteridge House 25/02/04

Cotteridge House 02/09/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Cotteridge House 31 Middleton Hall Road Kings Norton Birmingham West Midlands B30 1AB Lead Inspector Jill Brown Key Unannounced Inspection 28th June 2007 09:15 X10015.doc Version 1.40 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 Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotteridge House Address 31 Middleton Hall Road Kings Norton Birmingham West Midlands B30 1AB 0121 624 0506 F/P 0121 624 0506 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) Mrs Lyn Walker Mr Graham Walker Mrs Lyn Walker Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17 November 2005 Brief Description of the Service: Cotteridge House is registered to provide care for up to eleven persons of 65 years age or over. Nursing care is not provided by the home, district nurses visit the home as required. The home is situated within a pleasant residential area of Kings Norton. Local amenities are within a short walking distance. The large attractive Victorian premises have been sympathetically adapted for its current use. The property is set back from the main road, which permits off road parking for up to seven vehicles. Bedroom accommodation is located on both floors offering single or shared status. There is a lounge and separate dining room. Accommodation is comfortable, personalised and well maintained. All meal preparation and laundry services are provided on-site. The very attractive extensive rear garden is well laid out and well frequented by residents during clement weather. Staff provide a strong family culture and senior staff promote a a home for life ethos. Family and friends are welcomed and may stay for meals. Visitors are encouraged to participate in the care of their relative. The homes fees are between £320.28 and £400 per week. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited the home on a day in June without prior notice. A key inspection was undertaken which looked at all of the key standards. The inspection took place over 7 hours. During the inspection 2 residents were case tracked. This case tracking involved talking to the residents looking at all the records and information about them, looking at their medication, their rooms and talking to relatives and staff. This was to help the inspector make a judgement about the care given. Other residents and relatives were also spoken to and we received three comment cards. The inspector also took into account information we had received from all sources about the home since the last inspection. Information was given to us in an Annual Quality Assurance Assessment (AQAA), which the home completed. The AQAA shows how the home rates their performance in the areas set out in this report. We received this AQAA before the inspection. The home and we had received no complaints about this service since the last inspection. At the time of the inspection all the residents were female as were the care staff. What the service does well: The home collects information about the resident’s health and personal care needs before they are admitted to the home. In addition they collect information about residents life history and preferred lifestyles. This information helps to plan the care residents’ need. The care staff are well trained with almost all of the care staff having a National Vocational Qualification (NVQ) level 2 in care and a large number having achieved an NVQ level3. This means staff know how to care for residents appropriately. There are care plans in place; these are updated as residents needs change and routinely reviewed. Risks are identified and assessments are carried out to ensure that these can be minimised. Residents have their personal hygiene needs met and residents were assisted to choose their clothes, whether to wear make up, jewellery and so on. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 6 Residents’ health care was managed well with residents having access to equipment that assisted their health conditions. Records were kept on how to maintain the equipment and this should ensure that it continues to work well. Medication administration records matched the amounts of medication in the home for the residents’ case tracked. The medication system was safe. The small number of residents and the stable staff group ensured that residents have the benefit of staff that know them and their interests. The home provided traditionally English meals with plenty fruit and vegetables. Residents said that the food was good. Relatives spoken to were happy with the care the home gave to the residents. Relatives felt cared for when they visited. Residents and relatives spoken to had no concerns about the home. Staff have recently had training in abuse awareness and this ensures the safety of residents. The environment is homely and residents have a good relationship with each other. The arrangements for recruiting and training staff were good and staff that knew how to provide care protected this means residents. The home is managed and owned by Lyn Walker who has the training and experience to run a care home in the best interests of the residents. What has improved since the last inspection? What they could do better: Details about how residents are assisted to move should be written in their risk management plan. Further details of how residents about how residents’ oral care is managed should be in their care plan. Medication that was required to have special recording and storage was not stored and recorded in that way and this must be rectified. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 7 The building and the garden needed to be assessed for risks to residents and shortfalls rectified. The garden area needs to be secure and the paths clear of trip hazards. The wash hand basins must have a system of ensuring that the water temperature is safe without increasing the risk of bacteria in the pipes. The floor between the dining area and the lounge needs remedial action. The radiators must be risk assessed to ensure that the residents do not have the possibility of receiving a burn to their skin. The home needs to consider extending the stair lift to ensure that residents on the first floor can access that floor without having to climb stairs. There is a downstairs bedroom that has a frosted window leading on to the shower room and this does not ensure total privacy. The homes complaint procedure needed clarifying to ensure that the Social Services and the Commissions contact addresses were not the same. The manager need to ensure that there are no risks to residents by night staff not being trained in first aid. Although the home has good outcomes for residents due to good staff training and a stable staff group the home needed to ensure that paper work that underpins this practice is detailed. Further development was needed in the quality assurance systems so the home can improve year on year for residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are undertaken and these are detailed enough to ensure residents needs are met. Residents of the home can be assured that the staff are well trained to meet their needs. EVIDENCE: Although no residents have been admitted this year, records of the two residents case tracked suggest that residents are admitted following an assessment. Information collected about residents includes details about their health conditions, their usual routines such as time of rising and going to bed, their likes and dislikes about food and their personal hygiene support needs. In addition to this information about the resident’s life history and interests was collected. This information collection is important as it helps the home provide care that assists residents in the way they need and want. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 10 There are no male residents at present. The care staff group is all female, white Uk or white Irish as is the resident population. All the care staff have completed a National Vocational Qualification (NVQ) level 2 in care except for one member of staff who is undertaking this currently. A number of staff have completed an NVQ level 3. This means staff are trained in the care that the residents need. The home’s Annual Quality Assurance Assessment (AQAA) stated that this training also covers culture and diversity awareness. This ensures that residents’ heritage and preferred lifestyles are respected and efforts are made to meet these needs. Care staff were undertaking distance-learning course in dementia care at the time of the inspection. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have care plans that help ensure that their personal care and health needs are met. Residents health care needs are met and medication is administered appropriately and this means residents remain healthy for as long as possible. EVIDENCE: Care plans and risk assessments were in place for the needs identified at the point of assessment. The care plans were drawn up with the residents and were reviewed in depth three monthly. Improvements needed to be made to care plans and risk assessments but we recognise that due to the stability of the staff group and good staff training that the outcomes for residents were good. Residents were seen to have their hygiene needs were met. Residents were seen to have their nails painted, jeweller and make up on, if they wanted. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 12 These preferences were recorded in their care plan. Residents’ hygiene plans indicated what residents that could do for themselves except for oral care. There was not information to show whether the resident needed assistance, prompting or could manage this task themselves. Risk assessments for moving and handling detailed the number of staff required to assist the resident but did not show how the resident was to be transferred. Care plans were updated as resident’s needs changed. A communication plan was changed to reflect a change in a resident’s eye condition and an activity plan was amended to show an activity was no longer possible for a resident. Care plans and risk assessments matched the care given to residents. For example a nutritional assessment for a resident showed that the residents likes and dislikes in food and what aids they needed to support them to be independent. These aids were available to her at lunchtime. Residents’ weights were monitored and frail residents were seen to either increase or maintain their weight. Residents’ skin conditions were monitored and staff worked closely with the district nursing services. For example where a resident had gained a pressure sore in hospital, staff ensured that the district nurses instructions were followed and the pressure sore healed. Relatives spoke about the good skin care given. Residents were seen to have pressure-relieving equipment such as special cushions and mattresses where these were needed. The details of other specialised equipment were recorded in the care plan. In one plan details of how this equipment was to be used and the maintenance details were recorded and this was good practice. Where specialised care was needed this was detailed on the care plan and in one instance arrangements had been made for the staff to attend a course in the specialised care practice. The residents’ records detail separately visits from health professionals and the outcomes of these visits. This made it easy to track resident’s health care. Residents received visits from opticians, chiropodist and dentists, as these were needed. Medication was looked at for the two residents case tracked and the following found: Although there are photographs of residents with records these not kept with the Medication Administration Record (MAR). This is recommended as it acts as a check that medication is given to the right resident. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 13 The majority of medication arrives in a monitored dosage system that means that medication does not have to be taken out of separate packaging for each resident and medication. There were photocopies of the prescriptions and the medications found for the residents case tracked matched those prescriptions. The MAR had signatures of staff as they administered the medication. There were no gaps in these signatures without a reason being given for the gap such as the resident didn’t want pain relief at that time. A resident was on medication that needed specified storage and recording. The home had taken measures to ensure systems were in place to record, however the specified recording register and cupboard were needed. Counts of the ‘as required’ medication such as paracetamols were correct against the records, as was the medication for the residents case tracked. The Annual Quality Assurance Assessment (AQAA) stated that staff have received or were completing medication training. The staff training matrix showed that day staff have completed this training and night staff were in the process of completing this training. One resident’s care was reviewed by a social worker this year the social worker was told by the resident ‘I love everything about the home and the staff,’ another resident said ‘I’m very happy here they are very kind.’ One of the bedrooms has a window that leads on to the shower room and although this glass is frosted it does raise privacy issues. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are approached regularly to be involved in activities and conversation and this enhances residents’ lives. Relatives are made welcome in the home and can visit when they wanted and this ensures that residents have good social contact. Residents have a choice of well prepare and nutritious food, which helps, maintain their health. EVIDENCE: Residents were encouraged to join in activities and activities were developed for individual residents. One of the residents case tracked had an individualised activities plan, which involved the use of a number of community resources. The activities that she attended were an extension of activities she had attended prior to admission. This resident spent most of the day out on the day of the inspection. Residents were seen having conversations with one another and were assisted to undertake crosswords, word searches and so on. A resident said ‘ I like the musicals, (a member of staff name) here knows all the songs.’ The small number of residents and the Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 15 stable staff group mean that residents have the benefit of staff that know them and their interests. Families spoken to said that the staff are very friendly and speak to you. They felt welcomed into the home and cared for. A comment card received said ‘I can’t fault the service provided by the management and all the staff.’ Residents were able to spend time in their room if they wished or when they had visitors. Residents thought they could get up when they wish although they also said that they were early risers. One resident said that she tended to go to bed when the other ladies went. Another resident thought she got up when she wanted and went to bed when she wanted. Residents said the food was good. There is a cook available everyday. The home provided three weeks of menus of food they had provided. The food was of traditional English type and the residents preferred this. The breakfasts appeared to be cereals and toast. Although the residents spoken did not request this a cooked breakfast should be available on some days. Hot food options were available at most teatimes as well as sandwiches. The menus showed that vegetables and fruit were available every day. On the day of the inspection visit the inspector joined residents for the main meal of cottage pie and vegetables this was well cooked and tasty. Residents seemed to enjoy this. There was an alternative of sausages potatoes and vegetable if residents did not want this option. Residents received a good portion of food one resident on the table saying ‘oh I don’t know whether I can manage all of that.’ Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives were happy with the care provided and had no complaints. Residents are protected from abuse well trained staff that know them. EVIDENCE: The home and we have received no complaints since the last inspection. The home has surveys of residents’ views twice a year. The manager deals with any grumbles as and when they occur but a collection of these may show areas where the home can improve. The home has a complaints procedure that needs to show where the Director of Social Services is based and separate this from our address, as these are not the same organisation. The manager and a number of staff have attended a course on customer care. Relatives spoken to at the home had no complaints and said that the staff could not do enough to ensure that everything was in order. There have been no incidents of an adult protection nature reported to us since the last inspection. Staff received training in adult protection and abuse awareness last year. Residents spoken to raised no areas of concern. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment whilst homely need to be improved to ensure that any risks to residents are minimised. EVIDENCE: The home has been converted from a Victorian building and this means that although it provides a homely environment it may not meet the needs of all potential residents in the homes category of registration. There is good communal area space consisting of a large lounge with enough seating for the number residents. There is an attached dining area that over looks a pleasant garden. The flooring between the lounge and dining room needed some investigation as it flexed when walking on it and this may cause a resident to stumble. The lounge has a large television. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 18 The garden was in need of some attention partly due to the weather for weeks prior to the inspection. However a fence panel on one side of the garden was not in place that leads into the neighbour’s garden and the path at the side of the laundry needed attention to remove weeds and to ensure it is level enough to prevent trip hazards. Access to the first floor included a stair lift on the stairs however this did not extend to the five steps on the second flight of stairs. Residents that have a first floor bedroom would need to be able to manage these steps. The majority of the home’s bedrooms are on the first floor. One resident who spent the day in their room spoke of being too tired to come downstairs that day. There was an assisted bathing facility on the first floor containing an in bath lift and an assisted shower facility on the ground floor. These facilities were appropriate for the number of residents. Grab rails were not seen in all residents’ toilets and this may hinder residents maintaining their independence. Residents’ bedrooms were well furnished and well ordered however a number of rooms, although meeting the space requirements of homes registered before 2002, are unusual in shape. These irregular shapes give character to the rooms however can make it difficult to get all the furniture required by the standard into them comfortably and safely. Residents’ rooms were personalised with their belongings. Residents rooms had aids and adaptations to assist them where needed. One bedroom had a notice to remind the resident with short-term memory loss where they were, how long they had lived there and that they were safe. This detail can prevent a resident from becoming distressed. The home did not have low surface temperature radiators and a number of radiators were uncovered in high-risk areas such as bathrooms and toilets. It was difficult at this time of year to judge the potential risk of burns from these. The home did not have thermostatic regulators on the wash hand basins in the bedrooms. The manager stated that the thermostat control from the boiler had been lowered to control the water temperature and this may cause a risk of growth of bacteria in the water. The home was clean and fresh in all areas. The kitchen area had a visit from the Food safety department and they reported that the kitchen cleanliness and procedures were to a high standard. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The level of staff provided met the needs of the residents in the home. Staff were recruited well and there was an emphasis placed on training and this protects and supports the care of residents. EVIDENCE: The home’s rotas showed that the home plans to have two care staff on duty including the manager from 07.20 until 9pm. There are handover periods of ten minutes between each of the shifts. On a weekday the manager works 2 to 3 hours extra to fulfil her management responsibilities. There is one member of staff awake in the home over the night and another person lives on the 2nd floor of the home that can be called upon in an emergency. The home has a cook available everyday from 09.00 to 1.30 pm. This level of staffing was sufficient to provide good care for residents. Only one staff member has yet to receive a certificate for the completion of the National Vocational Qualification (NVQ) level 2 in care or above which was equal to 90 this exceeds the required standard. In addition to this 50 of the staff have achieved an NVQ3. This means that have the knowledge to deliver good care. The recruitment process for staff was robust and this protects residents. Staff files looked at showed that staff completed application forms and references Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 20 and Criminal Records Bureau checks were undertaken before staff were employed. Staff have job descriptions and the home ensures that new staff have read the policies and procedures that are kept in the home. There has been no new care staff employed so the homes induction process was not checked to see if it met the Skills for Care Common Induction standards. There is a good attitude towards training; staff meeting minutes showed that the home celebrated success in training. Staff receive regular update training on all the mandatory areas such as moving and handling and fire safety in a timely way. Additional training is given in areas such as dementia, incontinence and medication. Whilst it is difficult to ensure that night staff to receive appropriate training the home needed to risk assess the need to have night staff trained in first aid. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is experienced and knowledgeable and ensures that the home is run in the best interests of residents. EVIDENCE: The manager of this home is also the owner. She has extensive experience in the care of older people. She has a National Vocational Qualification (NVQ) 4 in care and holds the Registered Managers Award, which is a recognised certificate for the management of care homes. She includes herself in all the training that staff undertake which means her training is current. Whilst the outcomes for residents was good further development of the paperwork to underpin good practice and future development was needed. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 22 The home does not have a full quality assurance system however they have completed the Annual Quality Assurance Assessment (AQAA). The residents are given questionnaires twice a year to find out what they think about the service. They have devised another questionnaire to look at activities provided. A comment card provided by a relative stated that more small-scale activities would stimulate residents. They need to consider how they use the information from residents’ views to improve the service and to devise an annual report. Residents that needed help managing their personal money received this help. Records were kept of the balance of residents’ money held and receipts for any money taken out or spent on behalf of residents. The records showed that all required maintenance and inspection of services such as gas, electric and lifting equipment safety had been undertaken as required. Fire safety had been maintained by appropriate fire checks by the staff including fire drills and training and by outside contractors servicing fire equipment. There was a fire risk assessment in place but this should be checked against the new fire regulations to ensure this has the level of assessment required. Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 2 3 X X 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Controlled drugs must be stored in a CD cabinet and record their administration on the Medication Administration Record and in a controlled drug register. This is to ensure that such drugs are only given as prescribed and are stored securely. The garden fence panel must be replaced. The garden path must be made level. This is to ensure the safety of residents. The floor between the lounge 30/08/07 and the dining area requires investigation to ensure that residents do not stumble. A risk assessment of the 30/08/07 radiators must be carried out and action taken to ones that put residents of burning. A water risk assessment must be 30/08/07 carried to ensure that the water supply to residents is not so hot as to injure residents nor so cool not to prevent the growth of DS0000016899.V340369.R01.S.doc Version 5.2 Page 25 Timescale for action 30/08/07 2 OP19 23(2)(o) 30/08/07 3 OP19 23(2)(b) OP25 4 5 OP26 13(4)(c) 13(3) Cotteridge House bacteria. This is to ensure the health and well being of residents. A risk assessment must be 30/09/07 undertaken for the level of staff required to be trained in first aid. This number of staff must then be trained. This is to ensure that residents that become ill or have an accident have appropriate on site help. It also ensures that the workplace covered for any staff that become ill or have an accident. 6 OP30 13(4)(c) 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 4 5 6 Refer to Standard OP7 OP8 Good Practice Recommendations Care plans should detail assistance needed in all areas of identified need including oral care Residents that need assistance transferring from one place to another should have details of how this can be done safely. The home must consider the window from the bedroom to the shower room to ensure the privacy of residents. The complaints procedure should be reviewed to clarify the difference between Social Services and the Commission as this could cause confusion for residents and relatives. An extension to the existing stair lift must be considered to make the first floor fully accessible. The registered person must ensure a quality assurance system is fully implemented including consultation with stakeholders and draw up an annual development plan based on outcomes for residents. The fire risk assessment should be reviewed against the new fire regulations and amended where necessary. OP10 OP16 OP22 OP33 7 OP38 Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cotteridge House DS0000016899.V340369.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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