Inspection on 15/11/05 for Cowley Cottage

This inspection was carried out on 15th 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cowley Cottage 11/09/07

Cowley Cottage 19/05/06

Cowley Cottage 05/07/05

Cowley Cottage 15/10/04

Cowley Cottage 11/07/04

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

CARE HOME ADULTS 18-65 Cowley Cottage Ray Park Road Maidenhead Berkshire SL6 8PZ Lead Inspector Susan Burton Unannounced Inspection 15th November 2005 10:15 DS0000011287.V264293.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 DS0000011287.V264293.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. DS0000011287.V264293.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cowley Cottage Address Ray Park Road Maidenhead Berkshire SL6 8PZ 01628 638851 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) Care Management Group Limited Ms Geraldine Dummer Care Home 9 Category(ies) of Learning disability (9) registration, with number of places DS0000011287.V264293.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: The house is situated in a residential area of an attractive town on the River Thames. There are shops in the town though it is a distance to walk. The garden is shared with a second larger home on the same site. The staff and residents of both homes mix on a daily basis. Residents have access to a patio area and lawn. The home is based in a large detached house and has two distinct areas. The larger house provides accommodation for seven residents with communal space plus a two-bedroom apartment over two floors. All of the residents accommodation is single rooms. The residents in the larger house have moderate to mild learning disabilities and are all older men. Two females live in a separated area known as the Lodge and are supported to do more for themselves by the staff. DS0000011287.V264293.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which took place on Tuesday 15th November 2005 and commenced at 10.15. Since the last inspection in July a new resident had been admitted to the Lodge. Part of the inspection focused on the admission arrangements for the new resident and the resulting documentation. The inspection also looked at the environmental standards, dietary and menu choices and health and safety. At the time of the inspection three residents were in the house. The remaining four residents had chosen to take a weeks holiday in Isle of Wight. Two staff members were supporting the residents in the house and two staff members were accompanying the residents on holiday. What the service does well: What has improved since the last inspection? The home has acted on one recommendation from the last inspection report to ensure that CSCI details were added to its complaints policy. The problems found at the last inspection with a burst pipe have been repaired and all rooms redecorated and carpets relayed or replaced. DS0000011287.V264293.R01.S.doc Version 5.0 Page 6 What they could do better: 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. DS0000011287.V264293.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000011287.V264293.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 A new resident had recently been admitted to the home as an emergency. Assessment information was provided to the manager on the same day as the admission. The home does not have an emergency admission procedure, which should be developed. EVIDENCE: A needs assessment for the new admission was faxed over to the home on the same day as the resident was admitted; other documentation actually arrived with the resident. The individual had not had the opportunity to get to know the home or the other residents prior to her admission. The manager advised the inspector that emergency admissions are relatively unusual. The manager had to arrange and provide one-to-one staff support for the individual on admission and also provide intensive emotional and psychological support, which was currently ongoing and appeared to be most successful. The individual appears to have a much improved quality of life since her admission. The manager and staff team are commended for their efforts. The new residents review would be taking place later this month to give adequate time for the resident to settle in and the staff to get to know her well. The records seen evidenced a thorough and detailed assessment since her admission. DS0000011287.V264293.R01.S.doc Version 5.0 Page 9 The home does not have an emergency admission policy or procedure to assist the manager and staff in ensuring that admissions are appropriate and safeguard existing residents well being as well as the new admission. The manager had made sure that the new resident was informed of the homes rules and routines during the following days. DS0000011287.V264293.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): 6 Residents are appropriately assessed and their changing needs and personal goals were seen reflected in their care plans. EVIDENCE: The care plan of the new admission was in the process of being prepared for her review meeting. This document was seen to be well detailed and reflective of the individuals needs and aspirations. The individuals likes and dislikes were documented, appropriate risk assessments were in place and consultation in regard to activities had been undertaken. The plan also assessed health and psychological needs and the support required by staff, emotional needs, communication skills and a list of priorities with an action plan. The manager was currently acting as the individuals key worker. DS0000011287.V264293.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): 14,15,17 Four of the residents had chosen to take a weeks holiday, which was in addition to their summer holidays. One resident left during the inspection to spend a few days holiday with a friend. Residents are enabled to maintain family links and friendships. The menus in the home were drawn up in consultation with the residents and reflect their choice. Staff ensure that menus provide a varied and balanced nutritional content. EVIDENCE: The manager informed the inspector that the residents particularly enjoyed visiting a certain hotel on the Isle of White and was now a firm favourite. The residents had been to this particular hotel in the summer and had enjoyed it so much they had chosen to go back for another week. The summer holiday had also included the new resident who was able to confirm to the inspector how much she had enjoyed the break. This week away was seen as quite significant progress in maintaining her independence and confidence. DS0000011287.V264293.R01.S.doc Version 5.0 Page 12 During the inspection one individual was seen to be making arrangements to meet a friend to spend a few days away with her. Detailed travel plans were organised and the resident was appropriately supported by the manager to ensure her safety. Arrangements were put in place for a phone call to confirm she had arrived at the railway station to meet her friend and then daily phone calls during the visit to ensure everything was satisfactory. During the inspection a resident had her boyfriend visiting. Discussion with the manager evidenced that relationships are enabled and allowed to develop with the staff guidance and support. The new admission to the lodge meant that two females now share the small apartment, both were spoken to independently by the inspector and appeared to be relatively understanding and supportive of each others needs and emotions. Both were aware of the need for personal space for good days and bad days. The inspector looked at the homes menus and discussed with the manager the choices seen recorded. The manager advised the inspector that the residents are consulted at regular meetings and each individual chooses of one days menu, apart from Sunday where a traditional roast dinner is usually provided. The menus evidenced a range of meals and snacks chosen by the residents. The inspector discussed with the manager how a healthy nutritional balance is maintained, she was able to inform the inspector that residents weight and dietary needs are overviewed by the local GP and that previously all had been overweight and all were now within acceptable weight ranges for their age and ability. The inspector had lunch with three of the residents and was able to see the staff support provided to enable one individual to prepare his own snack while another was given a higher degree of support. DS0000011287.V264293.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): 18,21 Staff provide sensitive, flexible, personal support and care to the residents. The home has three residents over the age of 65 one of whom has health concerns. Training is needed to ensure that staff are aware of the care needs of older people. EVIDENCE: During the inspection the manager was seen to provide sensitive, flexible and appropriate support to the three residents in the home, all with differing needs. The younger female residents required very different more intensive emotional and psychological support, which was ably given. The new admission to the home was still requiring one-to-one intensive support from staff. Improvements had been made in the individuals personal hygiene and mobility. The manager and staff had supported the individual in the management of her weight and dietary needs and the resident was able to say how pleased she was with her successful weight loss. The individual had been seen immediately after admission by the local GP and had also been referred to a local psychologist. One resident in his 70s now has Alzheimers disease and also has poor physical health. The individual needed guidance and support throughout the day to DS0000011287.V264293.R01.S.doc Version 5.0 Page 14 maintain normal routines. Training had not been provided to enable staff to meet the aging needs of this resident. DS0000011287.V264293.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: DS0000011287.V264293.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Cowley Cottage and lodge provide a homely and comfortable environment for the residents. Residents bedrooms were seen to be furnished to suit individuals needs and lifestyles. The home provides a toilet and shower on the ground floor and a large bathroom on the first floor. There are no shared bedrooms. The home may wish to review the provision of aids and adaptations. The home is not provided with an infection control policy, which is reflective of current concerns and issues. EVIDENCE: Cowley Cottage and lodge sit in the grounds of Cowley house; there is a shared drive and garden to the side and a private area at the rear of the home. The home appeared to provide the residents with a homely and comfortable environment. The lodge has a separate entrance and is completely selfcontained. The manager advised the inspector that the organisation provides a very good maintenance service. The home was seen to be bright, cheerful, clean and free from any odours. DS0000011287.V264293.R01.S.doc Version 5.0 Page 17 A number of bedrooms were locked by the residents who were on holiday. The bedrooms that were seen by the inspector were large and airy and were furnished with up-to-date modern furnishings. The home has a cat flap provided for the residents pet cat. There is a small toilet and shower room with seating on the ground floor. Upstairs there is a large light and airy bathroom with a toilet. Both rooms were clean and tidy. No grab rails are provided to assist residents mobility, which may benefit from review. The communal lounge in the home was clean and tidy and comfortable. The home has a tiny laundry room under the stairs for its domestic washing machine. The kitchen is light and airy with a large dining table, which accommodates all of the residents. A new dishwasher had recently been installed. The lodge has its own lounge and kitchen, which were visited during the inspection and also found to be comfortable, clean and tidy. The home is recommended to review its provision of aids, adaptations and disability equipment as the residents age. The home may benefit from a formal review by an O.T to ensure that the mobility needs of its older residents are met; this would include safety systems and equipment as recommended by standard 29. The home did not have a specific infection control policy and procedure. The existing health and safety policy did not provide information to staff on how to deal with current issues and concerns such as MRSA, winter vomiting virus, scabies, hepatitis and TB. None of the staff in the home had been provided with infection control training, it is required that the manager be trained as soon as possible and that the organisation provides the home with an appropriate policy which gives guidance for staff. The homes domestic washing machine can wash up to 95°, the manager advised the inspector that Cowley House has an industrial washing machine which they can use if necessary. DS0000011287.V264293.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 None of the care staff will have achieved NVQ 2 or above by the end of 2005. At the time of inspection the manager and an agency member of staff were on duty supporting three residents in occupancy. The inspector found that the staffing arrangements for the cottage at the time of the inspection were sufficient to support the residents at home. Two members of staff were accompanying four residents currently on holiday. The home cannot effectively demonstrate its capacity to meet the assessed needs of those individuals with age related care needs. EVIDENCE: Cowley Cottage has three members of staff who have not yet achieved their NVQ 2, it is unlikely they will finish their training and achieve this standard by the end of the year. The number of staff on duty during the inspection were seen to be appropriate to support the needs of those residents at home. An agency member of staff was providing one-to-one care and support to a resident in the Lodge. The manager had been at the home for the previous evenings sleep-in nightshift and was working a day shift and would be relieved by the senior carer who would also cover the same hours for the next 24-hour period. The manager assured the inspector that of the two residents she was caring for one was DS0000011287.V264293.R01.S.doc Version 5.0 Page 19 mobile and virtually self-caring while the other needed greater degree of guidance and support. The inspector observed this to be an accurate reflection. Two members of staff had accompanied four residents for their weeks holiday to the Isle of Wight. The previous inspection recommended that training be provided for staff on the care needs of older people; this had not been followed up. Of the three residents over the age of 65 one has significant age-related health issues. The home cannot effectively demonstrate its capacity to meet the assessed needs of these residents. The training and development of staff should be linked to the homes aims and residents needs, which are not effectively evidenced. A staff training and development programme, which meets the needs of the residents and fulfils the aims of the home, should be available for inspection. DS0000011287.V264293.R01.S.doc Version 5.0 Page 20 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): 37,39,40,42 Manager has not yet completed the Registered Managers award. The home does not have available for inspection an annual development plan that is based on a systematic cycle of planning-action-review, which reflects the aims and outcomes for residents. The homes policies and procedures need to include emergency admissions and communicable diseases and infection control as recommended by Appendix 3 of the National Minimum Standards. The organisation is to confirm that it has met the fire deficiency notice issued by the Berkshire Fire and Rescue Service. Risk assessments for window restrictors and the security of the home are to be put in place. Food hygiene training needs to be updated. Infection control training is to be provided for the manager. EVIDENCE: DS0000011287.V264293.R01.S.doc Version 5.0 Page 21 The inspector discussed with the manager the progress she was making with her Registered Managers award. The manager advised the inspector that she was struggling as the assessor for her course had left and she now felt very demotivated. It is unlikely that the manager will achieve the award as recommended by the standard by the end of the year. The home did not have available for inspection an annual development plan that would evidence that there is a systematic cycle of planning, action and review, which reflects the aims and outcomes for residents in the home. The organisation needs to provide the home with policies and procedures as recommended by Appendix 3 of the National Minimum Standards. The home is required to have an appropriate to Communicable Disease and Infection Control policy and procedure and an Emergency Admission policy and procedure, see standard 4 and standard 30. An officer visited the home from the Berkshire Fire and Rescue Service in March 2005 and a fire deficiency notice was then issued. The manager advised the inspector that the organisation had confirmed in writing to the Fire Service at all deficiencies were now met. A copy of this letter is to be sent to CSCI. Food hygiene training requires updating for all staff. The manager is also required to be appropriately trained in infection control. Risk assessments are recommended for the lack of window restrictors and security arrangements for the home. The homes accident book was appropriately filled in and was confidentially filed. Service contracts were in place for the homes gas and electrical systems. Fire training had been provided and the testing of fire equipment and emergency lighting had been undertaken. DS0000011287.V264293.R01.S.doc Version 5.0 Page 22 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 3 X 2 X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 2 Standard No 37 38 39 40 41 42 43 Score 2 X 2 2 X 2 X DS0000011287.V264293.R01.S.doc Version 5.0 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA4 Regulation 14 Requirement The Registered Person ensures that a policy and procedure is developed for residents admitted to the home in an emergency. The Registered Person ensures that appropriate training is provided in the care of older people. The Registered Person ensures that an appropriate Infection Control policy and procedure is put in place. Training is to be provided for the Manager. Confirmation that the home has met the Fire Services Fire Deficiency Notice is to be sent to CSCI. Timescale for action 14/01/06 2 YA21 18 (1) (c) i 13 (3) 14/02/06 3 YA30 14/02/06 4 YA42 23(4) 14/12/05 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 YA29 Good Practice Recommendations The home reviews its provision of adaptations, aids and DS0000011287.V264293.R01.S.doc Version 5.0 Page 24 2 YA39 equipment to ensure that the needs of individuals are met. The home has an annual development plan, which reflects the aims and outcomes for the residents. This plan should be available for inspection. DS0000011287.V264293.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000011287.V264293.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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