Inspection on 19/12/05 for Cottisbraine House

This inspection was carried out on 19th December 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cottisbraine House 20/12/06

Cottisbraine House 19/05/05

Cottisbraine House 08/03/05

Cottisbraine House 22/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Cottisbraine House 36 Sandy Lane South Wallington Surrey SM6 9QZ Lead Inspector David Pennells Unannounced Inspection 19th December 2005 15:40 Cottisbraine House DS0000007152.V273417.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 Cottisbraine House DS0000007152.V273417.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. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cottisbraine House Address 36 Sandy Lane South Wallington Surrey SM6 9QZ 020 8647 7981 020 8647 7981 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 Maureen Ann George Mr Robert Daniel Brand Mr Robert Brand Care Home 11 Category(ies) of Learning disability (0) registration, with number of places Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow four specified service users over the age of 65 to be accommodated for as long as the home can provide an adequate service. 19th May 2005 Date of last inspection Brief Description of the Service: Cottisbraine House is a detached ‘family’-type residence situated on a fairly busy road connecting Wallington to Woodcote to the southeast of Sutton. The house currently provides a service to up to ten adults with a learning disability. The home is situated on a slope, being not particularly suitable for those who use wheelchairs, although access is possible from the sloping car park / driveway, and through the rear patio entrance into the sitting room. The accommodation provides a separate sitting and dining room and the kitchen is of ample, domestic size. Bedrooms are currently provided on a basis of two shared rooms (both currently singly occupied) and seven singles. Most bedrooms (7) have ensuite facilities. Access to the first floor is provided by stairs, or by using a (two stage) stair lift facility. An accessible shower is available on the ground floor (though not currently used/operable) and a bath on the first ‘mezzanine’ level - though this is accessed down a few substantial steps. Toilets are provided within these two bathing facilities. There is neither staff room nor designated office; the proprietors keep an amount of paper work in the second floor private sleeping-in facility, and in secured storage in the Hallway on the ground floor. External facilities provided comprise a small patio to the rear of the building accessed from the sitting room, and a small inclined, landscaped, car park / drive & front garden. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted late in the afternoon on a gloomy pre-Christmas weekday. The home was welcoming and warm and the single staff member present was able to assist the inspector with the inspection process – which, in the main, was focused on following-up issues raised in the previous inspection report and meeting with and finding out from the service users how they were and how they regarded the service. With only six service users actually residing at the home at the moment, with one already at home for the Christmas period, the remaining five were happy and eager with anticipation of the coming festival time. Carol singers from the local Bandon Hill Junior School (17 children!) had visited that morning with their teachers – the sixth service user returning with her relative to share this event with her fellow residents – and this had been thoroughly enjoyed by all. Most service users (whose average age is about 60) were decidedly tired that afternoon following this annual festive event! Having spoken to all service users, including one in private in their bedroom - and the second staff member who had arrived subsequently, the inspector examined documentation kept at the home and left just before 6.00pm. The current management arrangements at the home are that Mr Brand manages the fabric and general support services at the home and Mrs George oversees the care and catering. Moving away from a previously discussed intention to sell the service on, the proprietors now intend to continue running the home - but are seeking to appoint a suitably learning disability-qualified manager to carry out the day-to-day management tasks for them. This appointment will be to the best interests of all at the home – service users will receive a more professional perspective on their care and daily lives, staff will gain training and support in these and other areas, and the proprietors will have the peace of mind that the home is running competently in their absence. What the service does well: The home provides a very warm and homely intimate environment for service users to live in; staff members provide close attention to service users – this including, until quite recently, close on ‘palliative care’ provided in conjunction with the local district nursing service for a number of service users. Feedback elicited at the last inspection and from service users this time, all spoke generally highly of the care and service provided. The food served at the house is nutritious, home-cooked and plentiful; the kitchen is, indeed, the ‘hub’ of the house, with service users helping themselves and assisting in community life through preparing the meals and assisting with the clearing up afterwards. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 6 Life - socially, and engagement with the local community, is encouraged through attendance at various day centres and through evening clubs and other opportunities to go out with staff from the home. What has improved since the last inspection? What they could do better: A number of aspects from previous requirements including, most importantly, the ongoing requirement to appoint and propose for registration a qualified and competent manager - remain outstanding. Other issues outstanding (in summary) are: the service User Guide to be put in Makaton / service user-friendly version; the development of an assessment & familiarisation profile for new service users; evidencing the competence and Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 7 best practice of the service provided at the home; creating a version of the complaints procedure in Makaton / service user-friendly version; the development of a smoking policy / the development of induction & foundation training for new staff; the promotion of Care NVQ qualifications; the provision of professional staff supervision; the development of quality assurance mechanisms within the home; the production of a business & financial plan [amongst other long-term planning & development] for the home. It is probably quite obvious that a significant amount of these aforementioned requirements will be addressed and met once a competent manager is appointed; the inspector looks forward to working with the newly appointed person – for the benefit of the service users, staff, proprietors and the complete service. 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. Cottisbraine House DS0000007152.V273417.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 Cottisbraine House DS0000007152.V273417.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): 1, 2 & 3. Service users would be able to find out about life in the home from ‘live’ contact with staff and service users at the home – but have difficulty understanding and accessing information in written format. The service can provide an individual service user with care and attention, but requires an assessment tool in order to be able to discover, gauge and record the level and detail of an individual’s needs, preferences and aspirations. In order to assure a prospective service user of the quality of the service provided, the home must evidence more strongly their specific skills base in working with people with learning disabilities. EVIDENCE: The above judgement statements are taken from the last inspection report; the three requirements concerning [a] the service user guide being put in service-user friendly language, [b] the establishment of a new assessment and familiarisation tool and [c] improving the learning-disability focused skills base of the staff, were still outstanding – waiting on the building developments being currently implemented, in the home and the appointment of the new home’s manager. As admissions are currently being blocked to facilitate the house renovations, the issues are not significant – but the Statement of Purpose should be revised soon – in preparation for the home’s re-launch and the assessment tools will hopefully be required soon afterwards, to assist in the re-population of the home. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 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): None were directly inspected this time. Service users can expect to be supported by a current care plan with attendant risk assessments reflecting the needs and goals identified. Service users are encouraged to express their own personalities, choices and preferences – through being consulted either individually or as a group where appropriate. EVIDENCE: The above judgements statements are taken from the last inspection report, when the first four standards were assessed and all found ‘met’. There was nothing to suggest that the situation had changed since this last inspection. Care plans and day-to-day notes for service users were now in place and being constantly maintained. The ‘tick box’ personal care record continued – as did the record of food consumed. The home has some difficulty with involving some service users in elements of ‘participation’, due to the lack of capacity to comprehend such concepts. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 11 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): None were directly inspected this time. Service users have opportunities to develop their varying skills and to fulfil their spiritual needs, engaging in appropriate religious, day care, leisure/social activities - either as a group, or individually, at home / in the local community. Family and friends are made welcome at the house and service users are encouraged to develop appropriate relationships between themselves and with others in the wider community. Daily routines at the house encourage independence and service user’s rights to enjoy the house and the service in their own preferred way. EVIDENCE: The above judgement statements follow on from the last inspection – where all this section’s standards were inspected with the final standard concerning catering being awarded a ‘4’ to recognise the homely approach to providing food, snacks and celebration food in the home – ensuring a nutritious and enjoyable element for service users. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 12 In discussion with a staff member at the home this time, the progress of one of the more recently admitted service users was observed; the change in behaviour and the ‘coming out of their shell’ – with improved communication, self-expression and participation was noted. Another service user spoke of undertaking transport training presently – familiarising themselves with minicabs and working on expanding horizons of independent travel. They also attend the ‘People First’ Forum and find the house very convenient – being both close to Croydon & Sutton major town centres, with regard to accessing services and activities. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 13 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): 21. Service users can be assured of personal, respectful and specific attention to their personal care and support – including health care / medication needs. The home can provide suitably sensitive care and attention for service users at the point of serious illness / death, but would benefit from having sufficient information concerning ‘last wishes’ from all service users or their relatives / representatives - to ensure a focused, individual approach. EVIDENCE: “Oh yes – Maureen and Robert put the care first” – thus stated a service user who felt that the care provided to all was appropriate and sympathetic. It is certainly the inspector’s observation that service users have always been well ‘turned out’ - and have had their individual needs well met at the home. The medication cupboard and associated records were examined at the time of the inspection and again found to be generally in good order. The amount of medication used at the home is relatively small, allowing the very clear organisation of drugs in the cupboard. All staff members have had relatively recent training in this important area. ‘Last wishes’ information is still an area to be completed fully and remains a recommendation in this report. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 14 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. The home’s written complaints procedure is recognised and known by stakeholders, though a version in an accessible format for service users would be beneficial. Informally, the service provider is recognised to respond to comments and suggestions. The proprietors seek to ensure that service users are protected from harm or abuse, through recognising the local Adult Protection Procedure and through mechanisms such as external audits of financial transactions. EVIDENCE: A requirement that the home’s complaints procedure be made more accessible to service user through providing a Makaton / Symbols version has, still, yet to be carried out. It is hoped that the new manager will work on ensuring that all important information is suitably accessible to service users. The second judgement statement above reflects the assessment of the ‘Vulnerable Adults’ standard at the last inspection visit – which was ‘met’. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 & 30. Service users can expect to live in a clean and well-managed environment. The Communal lounge and dining facilities are homely, warm and comfortable. Communal toilets and bathrooms are suitable to service users. All areas of the home are safe and comfortable, and properly maintained, meeting each individual’s needs, with all basic amenities provided. Service user’s own bedrooms are distinctively different, and offer scope for the personalisation / individual characteristics that the home encourages. The planned renovation work at the home will ensure privacy and dignity in future for all service users, promoting independence and self-esteem. EVIDENCE: “The house is well looked after” – thus stated a service user who is keen-eyed when it comes to ensuring the place is clean and the fabric well maintained. One service user will soon have their room reduced in size (they are delighted) and are planning to make better use of a ‘cosy’ room – which will be provided with an ensuite shower as well. Currently issues about overbed lights, increasing the number of electrical socket outlets and providing shelving are outstanding – theses must be taken into account at the point of renovation. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 16 As an ‘existing home’, the current accommodation provided is - to some extent - acceptable to the Commission - on the basis of revised premises standards. However, some aspects are not covered by these exceptions, and the proprietors project to ensure that Cottisbraine House will continue well into this new century, reflecting as closely as possible the current minimum national standards. An undersize double room on the first floor is now singly occupied, awaiting conversion / reduction into a single room - this lending some of its space to the adjacent room (the currently smallest bedroom in the house - 8.1 sq. metres) – which will then be of adequate size. Both of these rooms will be ensuite. A recommendation –reflecting a service user’s comments suggests that the noise from the road in front of the house could be minimised if double-glazing were considered. The double bedroom on the ground floor is also projected to ‘give up’ some of its space to the creation of a small office for the soon-to-be appointed manager. The creation –through this work - of an all single-bedroom home will remove the need for an designated Visitor’s Room – and the reduction in numbers will ensure that communal space meets the new national standard. The bathroom on the ‘mezzanine floor is not necessarily accessible to all due to being on a half landing and steps leading into the room. Renovation plans are in hand to raise the floor level to that of the first floor. Meanwhile the shower facility on the ground floor is now working again – having been out of order for some time. One ground floor single bedroom to the rear is currently accessed directly off the dining room – which is not really appropriate - especially if soiled items have to be removed from the room. Plans are also now afoot to provide this room with an en-suite toilet and shower and a corridor to the hallway of the home – thus providing a fully private environment. The final ongoing situation - of staff smoking in the building (whereas no service users do so) - continues to be an unresolved dilemma. The home is sufficiently small that smoking in the entrance area / hallway causes a problem that service users have to walk through this area to access any room from any other. The smell of the smoke also travels into communal areas / bedrooms. For the sake of the service users, the home must be declared a smoking-free environment - and staff should smoke either completely away from service user areas, or go outside. The house, as ever, was well maintained – odour-free and clean. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 17 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, 35 & 36. The home provides staffing to meet the day-to-day needs of the service users and the establishment itself. Staff members could be better supported by a more developed staff induction, training and development programme / focus on the learning-disabled client group – this would bring clear benefits to the individual service users. Recruitment practices now ensure the safety of service users. Ongoing professional supervision and support must now be developed to ensure support for staff and to assist in the translation of the home’s philosophy and aims into work with individuals. EVIDENCE: The above judgement statements are based on the last inspection’s outcome, which has changed little. Staff members – who, clearly, are competent in their jobs - have generally been employed at the home for significant periods of time, and the proprietors are now awaiting the appointment of a suitable manager to undertake the elements of staff training and supervision that, hitherto, has been lacking at the home. The absence of a second member of staff present at the home was – the inspector was assured –a ‘one-off’ situation based on risk-assessed criteria. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 18 Staff training in Care at NVQ Level 2 or above is an area yet to be addressed by the home – currently only one care worker has an NVQ at Level 2, and another is a trained general nurse. This care training deficit is further evidence to illustrate where a qualified manager would be useful / instrumental in ensuring the home meets this National Minimum Standard target. The manager / proprietor has previously stated he is not intending to undertake training at a higher NVQ level for himself, as the expectation is that a qualified manager will come to be employed at the home soon. The home has not had to recruit staff recently – though there is some use of agency staff for occasional shifts to cover permanently employed staff member’s absences. Of those staff in post, all have now undertaken the CRB process of criminal records checks and staff files were noted at the last inspection visit to be much improved, now holding most information relating to revised Schedule 2 of the Care Homes Regulations. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 19 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, 40 & 43. Though overseen by two proprietors offering complementary skills in residential care, the home would benefit from focused management provided by a suitably qualified, competent and learning disability experienced manager. Although attempts are being made at addressing the issues of quality assurance, the home must aim to consolidate such areas to ensure that the home reflects the aspirations and opinions of service users and stakeholders. Policies and procedures at the home have now been expanded / revised to fully support the staff and the conduct of the home. To properly address the needs of the home in its entirety, a business and financial plan and suitable management systems need to be put in place to ensure the effectiveness, financial viability and accountability of the home. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 20 EVIDENCE: The above judgement statements reflect a similar situation to that of the last inspection – acknowledging the work, which has been undertaken to implement new policies and procedures (standard 40 now ‘met’), and also to acknowledger the fact that the manager’s post had been advertised widely in the Croydon Post and other local associated editions dated 14.12.05. The proprietors have got in place an excellent recruitment pack for the post of manager, and have indicated that the closing date early in the New Year will then ‘set the ball rolling’ for recruitment interviews and appointment to the post of manager - and subsequent proposal to the Commission for registration. The requirement associated with Standard 39 – concerning quality assurance and quality monitoring systems being integrated within the home’s practice and principles - was still outstanding. The manager has previously shown the inspector a questionnaire being developed for use with service users. A business and financial plan and suitable management systems was still to be put in place to ensure the effectiveness, financial viability and accountability of the home – though it is reflected that clearly with financiers being willing to back the renovations at the home, the home has a clear financial standing at present. Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 21 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 2 2 2 X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 X 2 2 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cottisbraine House Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X 2 3 X X 2 DS0000007152.V273417.R01.S.doc Version 5.0 Page 22 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 YA1 Regulation 5(1) Requirement The Service User Guide must be couched in suitable formats / language for the service users at the home and / or their representatives. Timescales of 30.05.04, 30.05.05 & 30.09.05 not met. Timescale for action 30/03/06 2. YA2 14 & 15 30/03/06 Assessment and familiarisation information - including a single assessment provided by the local authority - must be gathered by the home at the start of any new service user placement to ensure that a seamless transfer of care can be effected from the previous service provider. Timescale of 30.09.05 not met. The registered person must be able to more fully demonstrate the home’s ability to provide a service based on current good practice, reflecting relevant specialist knowledge. Timescales of 30.06.04, 30.05.05 & 30.09.05 not met. The Complaints procedure must DS0000007152.V273417.R01.S.doc 3. YA3 4(1) & 18(1) 30/03/06 4. YA22 22(5) 30/03/06 Page 23 Cottisbraine House Version 5.0 be simplified and converted to Symbol / Makaton form (or similar) to ensure it is more understandable to service users. Timescales of 30.07.04, 30.05.05 & 30.09.05 not met. 5. YA28 23(2)(h) A smoking area must be formally identified or the home should declare itself a ‘non-smoking’ establishment. Timescales of 30.06.04, 30.04.05 & 30.09.05 not met. Induction and Foundation training must be provided within the TOPSS Framework, and the NVQ training provided to staff must be LDAF-accredited. Timescales of 30.07.04, 30.04.05 & 30.09.05 not met. Staff supervision and annual appraisals must be introduced and meet the elements required in standard 36.4 5 6. Timescales of 30.07.04 & 30.04.05 not met. A competent and qualified manager must be urgently employed to lead the staff team and care service. Timescale of 30.09.05 not met – however advertisements have been published for this post and job packs have been issued. The entire element of Standard 39, containing requirements about quality assurance and quality monitoring systems must be integrated within the home’s practice and principles. Timescales of 30.07.04, 30.05.05 & 30.09.05 not met. 30/03/06 6. YA35 16(1) & 18(1)(c) 30/03/06 7. YA36 12(5)(a) & 18(2) 30/03/06 8. YA37 8&9 28/02/06 9. YA39 6 & 24 30/03/06 Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 24 10. YA43 24 & 25 A business and financial plan and 30/03/06 suitable management systems must be put in place to ensure the effectiveness, financial viability and accountability of the home. Timescales of 30.07.04, 30.04.05 & 30.09.05 not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA21 Good Practice Recommendations That the registered provider ensures that adequate information is kept on file concerning service user’s last wishes and steps to be taken if a service user is taken seriously ill. That the registered providers consider the possibility of double-glazing the front windows of the house particularly of bedrooms - to reduce the disturbance of traffic noise from outside. That 50 of Care Staff employed at the home must be qualified to NVQ Level 2 by the end of 2005. That the manager must be qualified in management and care to NVQ Level 4 by the end of 2005. 2. YA25 3. 4. YA32 YA37 Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Cottisbraine House DS0000007152.V273417.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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