Inspection on 05/07/05 for Cowley Cottage

This inspection was carried out on 5th July 2005.

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

Cowley Cottage 11/09/07

Cowley Cottage 19/05/06

Cowley Cottage 15/11/05

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 Sue Burton Unannounced 5 July 2005 at 09:40am 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 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 Stationary 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. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cowley Cottage Address Ray Park Road Maidenhead Berks SL6 8PZ 01628 63888851 Telephone number Fax number Email 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 Homes Limited Ms Geraldine Dummer Care home only (PC) Category(ies) of Learning disability (LD) registration, with number of places COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15 October 2004 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 can live in the flat and can be supported to do more for themselves by the staff, although at this time only one place is occupied. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection on Tuesday the 5th of July 2005. The inspection commenced at 09.40, and found the home in a crisis situation. A burst pipe had been found in a residents bedroom the day before, water was pouring through the kitchen ceiling and through the electrical fittings. Both plumbers and electricians were on-site trying to fix the problem. The manager and staff team had put emergency procedures in place for the comfort and safety of the residents. The inspector found that the interim measures put in place ensured the residents maintained as much of their normal routine as possible, some residents found the situation quite exciting while others did not appear to be affected; all were ably supported by the manager and her staff. The inspector was able to meet some of the residents before they left for their activities; the staff team was taking out other residents while the maintenance work was in progress. The inspection focused on the management standards and case tracked one resident who the inspector had been able to speak to. What the service does well: The manager of the home has many years experience in caring for older people which she uses to support the older residents in the home and shares this knowledge with her staff team. Despite the crisis residents were seen carrying on with their normal routine with minimum disruption, residents were being taken out for meals in various locations or having take-aways, which they appeared to enjoy. The residents in the two rooms affected upstairs had been offered alternative bed and breakfast accommodation with staff support, but had declined and preferred to stay in the home. Cowley Cottage has a real family atmosphere. The personal plans and documentation of the residents are kept in good order and are well detailed. The home has a comprehensive set of policies and procedures in place. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 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 standard(s) 1 The homes statement of purpose and service user guide was appropriate and met the needs of the residents and their families. There have been no new admissions since the last inspection. EVIDENCE: The homes statement of purpose and service user guide were seen to meet regulation and standard. Pictorial information is provided for residents. There have been no new admissions to the cottage since the last inspection, one of the female residents has since moved out and there is currently a vacancy in the apartment/flat. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6,7,8.9 Residents in the home are assessed appropriately and their changing needs documented and reflected in their plan. Residents are enabled to make decisions with staff support. The residents are consulted by the manager and her staff and are enabled to participate in all aspects of life in the cottage. Appropriate detailed risk assessments are in place. EVIDENCE: One resident’s documentation, which included personal plans, risk assessments, profiles, life picture, activity overview, daily diary, health needs and assessment of priorities were examined. The documentation was very organised, very detailed and gave staff information to enable the complete assessment of the residents changing needs and personal goals. The inspector heard and observed the manager and staff supporting the residents through the upheaval of the flooded bedrooms and kitchen. Those residents whose bedrooms were affected were offered choice in regard to their accommodation for the previous night and had decided to remain in the home with makeshift arrangements in place, which they preferred, to moving out to bed and breakfast accommodation. The inspector observed the discussions COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 10 that were taking place with the residents about what they wanted to do for that day and where they would like to eat. Some residents found the change interesting and somewhat enjoyable and others appeared only minimally concerned. The documentation supported that the individual resident case tracked was assisted by the staff team to manage his finances as independently as was safe to do so. The home has regular monthly meetings for the residents where issues are discussed, for example each resident chooses one days meals for the next weeks menu. The risk assessments of two individuals were examined and were found to be appropriate and fully detailed. The risk assessments were last reviewed in January, the manager advised the inspector they were due for review very shortly. A discussion took place with the manager in regard to those residents who smoked and health education issues. The home may wish to consider a risk assessment for the health needs of smokers in the home. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,16 Residents in the cottage are provided with opportunities for personal development, take part in appropriate activities and are part of the community. The residents have appropriate personal and family relationships, which are enabled and supported by the staff. Residence rights are respected and their responsibilities recognised. EVIDENCE: Documents were seen to record resident’s visits to the local church on Sundays. Three of residents in the home are over retirement age and personal plans were seen to record their hobbies and leisure interests. These included visits to the local pub, line dancing, feeding the ducks, arts and crafts and watching TV. All eight residents had recently been on holiday to Blackpool where theyd stayed in a four-star hotel, the organisation had paid £250 towards each resident costs. The manager advised the inspector that family contact is maintained and is important to the residents well-being, evidence was seen of family input into COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 12 decision-making processes and the management of a residents financial situation. Personal relationships were documented and acknowledged by the staff and supported where appropriate. The homes daily routines were completely disrupted by the flood but staff were managing the crisis calmly and responsibly and were supporting the residents appropriately. Some residents needed differing degrees of support due to their age ranges, the inspector observed the manager and her staff supporting all levels appropriately. Evidence was seen and discussion took place around household chores and tasks delegated to residents. The delegated tasks did not appear onerous and were relevant to each individuals ability. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 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 standard(s) 18,19,20 inpart,21 Residents in the home receive the level of support they need. Residents physical and emotional health needs were seen to be met. Training would enhance the care staffs understanding of the needs of older people. A requirement in regard to medication from the previous inspection had been addressed. Individual’s needs in regard to ageing illness and death are met. EVIDENCE: The resident health needs were well documented and information seen recorded evidenced that specialist health care needs are understood and met. A requirement from the previous inspection that medication administration records are accurate was seen to be addressed from a review of the medication charts. Three residents in the home are over retirement age, one of which has specialist needs. The manager has previous experience, skills and knowledge that enabled her to meet those needs. Each resident had recorded their personal wishes in the event of the death with the support of family or staff. The organisation has a dying with dignity policy. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 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 standard(s) 22,23 The home has an effective complaints procedure; residents and familys views are listened to and acted on. Procedures are in place to protect service users from abuse and neglect or harm. EVIDENCE: A review of the homes complaints log revealed that one complaint had been made since the last inspection from a member of a residents family. The complaint involved a request for information which a resident had not wished to be given, a written response was sent by the manager and was appropriate for the protection of the residents wishes. It is recommended the organisation includes CSCI details in its policy; this information was recorded in the service user guide and statement of purpose. The home has a comprehensive policy and procedure in place for the protection of its residents, local guidelines were also available, the manager advised the inspector that POVA training for staff is updated each year. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 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 standard(s) None of these standards were inspected due to major repair work taking place. EVIDENCE: COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 All staff are provided with job descriptions and are aware of their roles and responsibilities. The home has not achieved 50 of its staff with NVQ 2. A requirement from the last inspection had been addressed with the appointment of a senior member of staff. Residents are protected by appropriate recruitment procedures. Induction training has been provided for a new member of staff. The training and development of staff needs further improvement. EVIDENCE: An established member of staff had recently been promoted to deputy manager following a requirement made at the last inspection. He had been provided with a job description, appropriate induction and support. All staff have been given copies of the Social Care Council’s guidelines and code of conduct. The manager advised that two members of staff are expected to commence their NVQ’s in the near future. The standard is unmet until 50 of staff achieve NVQ2 by 2005. There are no members of staff currently using the Learning Disability Award Framework training. It is recommended that the staff team receive training to improve their knowledge base in regard to the needs of older people. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 17 The manager advised the inspector that mandatory training is provided on a rolling programme. The recruitment records of one member of staff were examined and documentation evidenced an appropriate recruitment procedure. The manager gives monthly supervision to all members of staff, records examined were very detailed and appropriate. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) In 37,38,39 The manager of the home is competent and experienced to run the home and is undertaking the registered managers award. The management ethos of the home created an open, positive and friendly atmosphere. The home has regular meetings with residents to hear their views and discuss any issues with them. The home has a comprehensive policy and procedure file. EVIDENCE: The manager has been in post for a number of years, and knows the residents well. She has previous experience of caring for the needs of older people before moving into learning disability. She is currently undertaking the registered managers award. The standard is unmet until verification that the award has been gained which is recommended by 2005, and is available for inspection. She has undertaken training recently in appraisal skills and emergency first aid. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 19 The notes of residents meetings and the resident’s daily diary evidence that feedback is actively sought and recorded, the views of the residents were encouraged and noted. The organisation has sent out questionnaires to family and advocates asking for feedback on the service, the responses were available for inspection and provided evidence of their satisfaction with the service. The manager provided the inspector with a large comprehensive policy and procedure file which staff are encouraged to read at appropriate times. COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 20 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 3 x x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 COWLEY COTTAGE Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x x x H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 21 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 Regulation Requirement Timescale for action 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. Refer to Standard 22 32 35 37 Good Practice Recommendations The organisations complaints policy contains CSCI details. 50 of staff in the home achieve NVQ2 by 2005 Training is provided for care staff in the needs of older people. The manager achieves NVQ4/Registered Managers Award by 2005 COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Parkl Theale 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 COWLEY COTTAGE H52 H01 11287 Cowley Cottage V232092 050705 Stage 4.doc Version 1.30 Page 23 - 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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