Inspection on 11/10/05 for Cowley House

This inspection was carried out on 11th October 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 House 17/12/08

Cowley House 28/12/07

Cowley House 23/07/06

Cowley House 18/04/05

Cowley House 23/08/04

Cowley House 07/06/04

Cowley House 07/03/04

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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 House Ray Park Road Maidenhead Berkshire SL6 8PZ Lead Inspector Marie Carvell Unannounced Inspection 11th October 2005 1:20pm DS0000011288.V249611.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 DS0000011288.V249611.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. DS0000011288.V249611.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cowley House 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 Jacqueline Tracy Duggan Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000011288.V249611.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 2005 Brief Description of the Service: Cowley House is registered to provide accommodation and care for up to twelve service users, aged between eighteen and sixty five years of age, whose care needs, arise from learning disability. The range of care needs within the home is diverse and complex. Several service users have needs, which can challenge the service. DS0000011288.V249611.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection unannounced on a week day afternoon from 1.20pm until 5.45pm. A tour of the communal areas of the home and several bedrooms at the invitation of the service users, were seen. A sample of service user, staff and records required to be kept in the home, including health, safety and fire were examined. Time was spent with several service users, staff on duty and the manager who came to the home to assist with the inspection. At the last inspection in April 2005, five requirements were made These were that a procedure is developed is developed for service users admitted to the home in a emergency, that service users are provided with a copy of the purchase agreement between purchasing authority and service provider, that the administration of “PRN” medication must comply with company policy, that a staff training and development programme is developed and that an annual development plan is produced. Two requirements have not been complied with, with one outstanding from September 2004. Failure to comply could result in enforcement action being taken. What the service does well: What has improved since the last inspection? DS0000011288.V249611.R01.S.doc Version 5.0 Page 6 The home has recently submitted an application to register the home for LD and LD (E) as five of the service users are over the age of sixty five years, and have lived in the home for many years. 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. DS0000011288.V249611.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 DS0000011288.V249611.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): 4 There is a detailed admissions procedure for planned admissions to the home. However, an admissions procedure needs to be developed for emergency admissions to the home. EVIDENCE: One service was admitted to the home as an emergency placement and therefore was unable to visit the home prior to moving in. A requirement was made at the last inspection in April 2005 that a procedure is developed for service users admitted in an emergency. This has not been complied with. DS0000011288.V249611.R01.S.doc Version 5.0 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 the following standard(s): None of these standards were inspected. EVIDENCE: DS0000011288.V249611.R01.S.doc Version 5.0 Page 10 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): 17 A varied and healthy diet is provided based on the food preferences of service users. EVIDENCE: Several service users are involved with menu planning, food shopping and meal preparation. Food stocks were plentiful with fresh vegetable, salad and bowls of fruit available for service users. One service user showed the inspector a cake he had baked the previous day. Several members of staff have attended a seminar on diet and nutrition. Dietician advice is sought on specific dietary needs. Menus and food records are well maintained. It was noted that two consecutive meals serviced had been sausages, however, this had been the meal choice of at least one service user. DS0000011288.V249611.R01.S.doc Version 5.0 Page 11 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): 20 Medication is administered in a safe and appropriate manner. EVIDENCE: Since the last inspection the administration of PRN (when required) medication has improved and now follows the correct procedure. The manager is developing guidelines for when and in what circumstances PRN medication is administered. This will be developed with input from the visiting GP. Medication administration records were seen to be well maintained with no obvious gaps in recordings. Medication is stored securely in a locked metal cabinet. DS0000011288.V249611.R01.S.doc Version 5.0 Page 12 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 and 23 The home has a comprehensive complaints procedure and protects service users from abuse. EVIDENCE: The home has a comprehensive complaints procedure; a copy of the complaints procedure is given to all service users and displayed in the home. Two complaints by a service user were recorded in the complaints book. The manager is taking steps to address the issues identified. All staff have received training in the protection of vulnerable adults from abuse. One new member of staff is booked on the next available course. A copy of the Multi-Agency procedures is available for all staff in the home. DS0000011288.V249611.R01.S.doc Version 5.0 Page 13 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 and 30 The home is comfortable, safe and meets the needs of the service users. EVIDENCE: Service users expressed their satisfaction of the accommodation and facilities available to them. Appropriate aids and adaptations are in place to meet the specific needs of service users. The premises were seen to be clean, comfortable and homely. One bedroom and the upstairs landing smelled of faeces and stale body odour. The manager is taking steps to address this issue. There is a daily cleaning programme in place, senior staff monitors this. DS0000011288.V249611.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The home continues to have several staff vacancies. There is a core of experienced staff in the home, who know the needs of the service users well. There is a need to ensure that the duty roster accurately reflect the staff on duty. EVIDENCE: Staffing levels have been increased to meet the assessed needs of the service users. The duty roster demonstrated that the manager, deputy manager and three support workers were on duty between 7am and 2.45pm. The manager was actually working from home, but came in at 2.30pm to assist with the inspection and one of the support workers on duty had started working in the home the day before and was “on induction” and was supernumery to the staff team. The duty roster for the evening shift demonstrated that a senior support worker and two support workers were on duty. However, an additional member of staff was working the evening shift having taken a service user to a hospital appointment during the afternoon. Staff told the inspector that activities were dependent on staff availability, as one service user required two members of staff to accompany the service user on outings. DS0000011288.V249611.R01.S.doc Version 5.0 Page 15 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): 39 and 42 There is a need to produce an annual development plan for the home. Health, safety and service user welfare is safeguarded. EVIDENCE: A requirement was made in August 2004, which an Annual Development Plan for the home is produced, with a timescale of September 2004. This was found to be unmet and an additional timescale was given for June 2005. Again this has not been complied with. The provider is reminded that failure to comply with this requirement could result in enforcement action being taken. Health and safety maintenance checks are completed on a regular basis and records are well maintained and up to date. DS0000011288.V249611.R01.S.doc Version 5.0 Page 16 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 x x 2 x Standard No 22 23 Score 3 3 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 x x x x x 2 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 x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 3 x DS0000011288.V249611.R01.S.doc Version 5.0 Page 17 Yes two 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 That the provider ensures that a procedure is developed for service users admitted to the home in an emergency. Previous timescale of 18/06/05 not met. That the manager makes the necessary arrangements for sufficient staff to be on duty to meet the assessed needs of all service users. That the manager ensures that the duty roster reflects, accurately staff on duty. That the provider makes arrangements for an annual development plan to be produced and a copy sent to the CSCI. Previous timescale of 18/06/05 not met. Timescale for action 11/12/05 2 YA33 18 11/11/05 3 4 YA33 YA39 17 and Sch 3 24 11/11/05 11/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000011288.V249611.R01.S.doc Version 5.0 Page 18 Standard DS0000011288.V249611.R01.S.doc Version 5.0 Page 19 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 DS0000011288.V249611.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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