Inspection on 28/12/07 for Cowley House

This inspection was carried out on 28th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Cowley House 17/12/08

Cowley House 23/07/06

Cowley House 11/10/05

Cowley House 18/04/05

Cowley House 23/08/04

Cowley House 07/06/04

Cowley House 07/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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 28 December 2007 10:45 th DS0000011288.V345438.R01.S.doc Version 5.2 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.V345438.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V345438.R01.S.doc Version 5.2 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Ms Jacqueline Tracy Duggan Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places DS0000011288.V345438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd July 2006 Brief Description of the Service: Cowley House is registered to provide accommodation and care for up to twelve service users, 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. The home is registered to accommodate service users over the age of eighteen years; many of the current service users are over the age of sixty-five. The current scale of charges as at December 2007 is between £ 514.20 and £1358.44 per week. There are additional charges for toiletries, chiropody, magazines, some activities and holidays. DS0000011288.V345438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘key Inspection’. The inspector arrived at the service at 10.45 am and was in the service until 4.30 pm. It was a thorough look at how well the service was doing, and took into account detailed information provided by the deputy manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection. Eight service users, four relatives of service users and four healthcare professionals responded to surveys that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. Time was spent with the majority of the service users, staff on duty and from 12.30pm, the deputy manager, who was officially on annual leave but came on duty to assist with the inspection. A tour of the premises was carried out and a sample of records required to be kept in the home were examined, including the case tracking of three service user’s files. At the last inspection undertaken seven requirements were made, these are referred to in the body of the report. Feedback was given to the senior support worker and deputy manager throughout the inspection. What the service does well: Visitors are welcome to visit at any time and service users from Cowley Cottage are invited to some activities and birthday celebrations. Service users are involved with menu planning and food shopping. Menus demonstrated that a varied and balanced diet is provided and a record is maintained of food eaten by service users. Food stocks were plentiful with fresh fruit, vegetables and salad. One service user enjoys cooking and assists staff with some food preparation. Staff that have received appropriate training administer medication. Medication administration records and storage were seen to be satisfactory. Appropriate guidelines are in place for service users prescribed medication to be taken PRN (when required). None of the current service users retain, administer or control their own medication. DS0000011288.V345438.R01.S.doc Version 5.2 Page 6 The home is in good decorative order and furniture is of a good standard. Service users expressed their satisfaction of the home and its facilities. What has improved since the last inspection? What they could do better: New service users must only be admitted to the home following a full assessment undertaken by people competent to do so. Evidence must be available to demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. Prospective service users should be able to visit the home on an introductory basis before making a decision to move there and unplanned admissions are avoided where possible. Make arrangements for service users to take part in valued and fulfilling activities, which are age, peer and culturally appropriate. Service user must be provided with flexible personal support to maximise their privacy, dignity, independence and control over their lives. All complaints received must be recorded in line with the home’s complaints procedure. All staff must be provided with training safeguarding adults from being harmed or suffering abuse. A system for contacting staff on duty in the home, in an emergency, such as a call alarm/ mobile alarm must be installed. Ensure that at all times there are suitably qualified, competent and experienced persons are on duty in sufficient numbers as are appropriate for the health and welfare of the service users. Recruitment procedures in the home must be more robust to protect service users from possible harm. DS0000011288.V345438.R01.S.doc Version 5.2 Page 7 All staff must be provided with training appropriate to meeting the needs of the service users. That all staff are supervised and this meets the home’s supervision policy The deputy/ acting manager should be given sufficient allocated time to undertake his management tasks. That all staff are provided with training in moving and handling, infection control and food hygiene. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000011288.V345438.R01.S.doc Version 5.2 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 DS0000011288.V345438.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2,3,4 and 5. Quality in this outcome area is poor. The home has a comprehensive admissions procedure. However, it was not evidenced that that all service users are assessed prior to admission or given the opportunity to visit the home before moving in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, one service user has been admitted to the home. No evidence was available on file as to the reason for admission; no assessment of need had been undertaken, no evidence as to the views of the service user or his/her family being taken into consideration, no evidence of a trial period or review having taken place with the service user, home staff and purchasing authority. Staff on duty confirmed that it became apparent within days of the service user being admitted that the home did not have sufficient, trained, knowledgeable staff to meet the care needs of this service user and this was resulting in the service user receiving a poor quality of care and also having a major impact on the other service users in the home. It is understood that a DS0000011288.V345438.R01.S.doc Version 5.2 Page 10 meeting is to be requested with the funding authority to discuss a more appropriate placement being found. The service user has not received a copy of the contract between the funding authority and care provider. The service user has a copy of the service users terms and conditions with the home; this did not include fees payable and was not signed or dated. DS0000011288.V345438.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is adequate. Service users have comprehensive care plans and appropriate risk assessments in place. It was not evidenced that service users’ are involved as much as possible, with decision making. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have comprehensive care plans and risk assessments in place and these are reviewed on a regular basis. Not all care plans evidence that service user are consulted about their care plan or signed and dated. All service users have a named key worker. The service user most recently admitted to the home has a care plan and risk assessments in place, these were dated some time after the service user’s admission to the home and did not evidence that the service user had been DS0000011288.V345438.R01.S.doc Version 5.2 Page 12 involved in the care planning process. It is unclear how staff were able to draw up a care plan, when no assessment had been undertaken and staff confirmed that very little information was available about the service user. Behavioural guidelines are in place for inappropriate shouting, general interaction, damage to property, physical aggression and behaviour in the community. It was not clear who had drawn up the guidelines, which were unsigned and undated but had been sent with the service user from his/her previous care home. Staff on duty confirmed that a request had been made to the Community Behavioural Specialist team for assistance, although no one from the service had yet contacted the home. Information on file referred to the service user needing 2.1 support as the service user has behaviours that challenge the service. Staff on duty confirmed that they did not the necessary skills or experience and frequently felt ‘ out of their depth’ when providing care to the service user. Comments made on surveys completed by relatives included ‘ my X now feels that this is X home, due to the care X receives from the staff. X is treated as a valued member of the household and is encouraged to help with the cooking, which is something x enjoys’, ‘ I feel that x is well looked after in every respect’, ‘I am very pleased with the care my x gets at the home’. Comments made on the survey completed by a service user included ‘I would like to move to a smaller care home as I don’t like noise and some of the service users’. All eight surveys completed by service users with assistance from a member of staff, confirmed that they received the care and support they needed. In discussion with service users it was evident that there was a good rapport between service users and the staff team. Most service users were able to name their key worker. Staff on duty were observed encouraging service users to make their own decisions and choices, this tends to be those service users whose communication styles are more easily understood by care staff. Individuals with more diverse needs find it harder to have their opinions listened to. One service user is not able to communicate verbally and it was agreed prior to the service user’s admission to the home that all staff would undertake sign language training. This has not been actioned. DS0000011288.V345438.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17. Quality in this outcome area is adequate. Not all service users are able to access leisure opportunities or be part of the local community. Menus are based on the food preferences of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have a weekly activities sheet and activities undertaken are recorded in service user’s diaries. The activity sheet is displayed in the dining room. One service user said ‘No one takes any notice of what is written on that’. Generally staff are aware of the need to support service users to develop their skills, including social, emotional, communication and independent living skills, but this process could be improved. Three service users attend a range of day services several times per week. One service user has no organised day DS0000011288.V345438.R01.S.doc Version 5.2 Page 14 services by choice and spends most days away from the home; staff were unclear as to how this service user spends his/her time each day. The home is close to town of Maidenhead and within walking distance of shops, parks and leisure facilities. The home has a minibus and trips out are arranged. This is dependent on staffing levels and it was evidenced that some activities including music therapy sessions have been cancelled due to lack of staff being on duty. Two service users, who have behaviours, which challenge the service and require two members of staff to be present during any community presence, are no able to go out, due to the home’s staffing levels. One service user is funded for 1-1 support from 10am until 8pm each day. It was not evidenced that the service user was receiving this level of support. During the afternoon of this visit staff were observed spending time with service users as a group as well as with individual service users, watching television, reading and drawing. Several service users said that they had a very nice Christmas with lots to eat and presents. Visitors are welcome to visit at any time and service users from Cowley Cottage are invited to some activities and birthday celebrations. Service users’ rights and responsibilities are respected and this was evidenced in discussion with service users, staff on duty and from observation. Staff try to ensure that daily routines are relaxed and flexible to meet service user preferences, but it was acknowledged that at times this is not achieved. As in many other care homes, there is a wider range of racial, ethnic and faith backgrounds represented within the staff group compared with the current service users. From discussion with the deputy manager, the inspector considers that the home would be able to provide a service to meet the needs of individual service users of various religious, racial or cultural needs. There are indications that service users sometimes find that some staff cannot communicate satisfactorily because English is not their first language. Service users are involved with menu planning and food shopping. Menus demonstrated that a varied and balanced diet is provided and a record is maintained of food eaten by service users. Food stocks were plentiful with fresh fruit, vegetables and salad. One service user enjoys cooking and assists staff with some food preparation. DS0000011288.V345438.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is adequate. Service users personal care needs are not always provided in the way they prefer and require. Healthcare needs are not always met. Medication storage, administration and recording are well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users personal care needs are recorded in care plans. Personal care given during the day is recorded in service user’s diaries. At times personal care is not provided due to the service users’ aggressive behaviour towards staff. Due to lack of staff knowledge and training, staff deal with challenging behaviours by withdrawing from the service user involved. For the majority of service users their healthcare needs are met. Records indicated that the healthcare needs of one service user are not met, as healthcare input was not put into place before the service user was admitted to the home. This remains an ongoing issue. Comments made on surveys completed by healthcare professionals included ‘ the previous manager worked DS0000011288.V345438.R01.S.doc Version 5.2 Page 16 extremely well with clients with a forensic history’, ‘ the home needs to continue to improve upon the work of the previous manager’,’ supports the individual with choice, respect and dignity’, ‘ I have not been aware of any behaviour toward residents that gives me cause for concern. Each resident has very different needs but I feel that they are treated as individuals. Whenever I have recommended specific care the advice has always been carried out’. Comments made on surveys completed by healthcare professionals about how the care home could be improved included ‘ communicate information/concerns better and more directly i.e. not cancelling visits etc. wasting professional time. Being more organised’, ‘’ ensuring that there is a qualified manager to cover maternity leave’. Staff that have received appropriate training administer medication. Medication administration records and storage were seen to be satisfactory. Appropriate guidelines are in place for service users prescribed medication to be taken PRN (when required). None of the current service users retain, administer or control their own medication. DS0000011288.V345438.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. The home has a complaints procedure in place and procedures are in place to protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place, this is displayed on the notice board and is in a pictorial format. Service users able to give an opinion said that if they had a complaint or concern then they speak to the deputy manager or staff on duty and felt that any complaints are addressed. Two of the four relatives who completed a survey confirmed that they were aware of how to make a complaint. Information received from the deputy manager confirmed that the home has not received any complaints since the last inspection. From discussion with service users and other documentation seen, complaints have been made but have not been recorded. The Commission has received no information concerning complaints about this service since the last inspection. There are policies and procedures for safeguarding adults and whistle blowing. Copies of these policies and procedures are displayed in the manager’s office. Staff on duty were aware of the procedures and said that they would read the information if necessary. Not all staff have received safeguarding adults DS0000011288.V345438.R01.S.doc Version 5.2 Page 18 training, some of the staff who have received training provided by previous employers or was undertaken in early 2004. No adult protection investigations have been undertaken since the last inspection and no referrals have been made for inclusion on the POVA (Protection of Vulnerable Adults list). Policies and procedures are in place for dealing with service user’s monies. The home holds small amounts of money for service users day-to-day requirements. Clear, detailed and up to date records are maintained of all expenditure undertaken on behalf of the service user. A member of staff signs each transaction and receipts are obtained. DS0000011288.V345438.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,29 and 30. Standard 29 was subject to requirement at the last inspection. Quality in this outcome area is good. The home is homely, comfortable and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is in good decorative order and furniture is of a good standard. Service users expressed their satisfaction of the home and its facilities. At the last inspection a requirement was made to provide safe access to the rear garden for service users with reduced mobility. This has been addressed. At the invitation of two service users, their bedrooms were seen. Bedrooms are appropriately furnished and reflect the personality of the service user. Although the home is registered for twelve service users, this includes two double bedrooms. The ten service users currently living in the home all have a single occupancy bedroom. DS0000011288.V345438.R01.S.doc Version 5.2 Page 20 Appropriate aids have been fitted in the first floor bathroom and ground and first floor shower room. The home does not have an emergency call system in place and on previous visits to the home, staff had been provided with mobile alarms to call for assistance from other staff in the event of an emergency whilst providing service users with personal care. Staff confirmed that there are no mobile alarms in place and in the event of an emergency, would need to shout for assistance. This was discussed with the deputy manager during the inspection about action needing to be taken. The home was seen to be clean, fresh smelling and hygienic. DS0000011288.V345438.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36. Standards 32,34,35 and 36 were subject to requirement at the last inspection. Quality in this outcome area is Poor. Staffing levels are insufficient to meet the needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection seven full time support staff have left the home. The inspector was advised that staffing levels have been reduced and now consist of three members of staff on each shift during the day and two waking staff on night duty. The home no longer employs a cleaner and all cleaning, catering and laundry tasks are undertaken by staff on duty. In discussion with staff on duty comments were made that staff do their best to meet the needs of service users, but there is a constant stress with providing care to service users at a time of their choice, cleaning, laundry and catering with the need to complete administrative tasks in the home. At the last inspection a requirement was made that action should be taken to achieve 50 0f support staff with National Vocational Training (NVQ) level II. DS0000011288.V345438.R01.S.doc Version 5.2 Page 22 Three of the fifteen, full time, part time and bank support workers have achieved NVQ level II in June 2007. It is hoped that a further five members of staff will be considered for NVQ training late January 2008. From discussion with staff on duty, observation and examination of the duty rosters, staffing levels are insufficient to meet the needs of the service users. Records of two service users state that they require 2-1 attention, due to specific care needs. One service user is funded for 1-1 support from 10am until 8pm each day and one service user requires 1-1 support with all activities outside the home. Staffing levels was raised as a reason for the high turnover of staff. There are twelve permanent staff in post including the deputy manager contracted to work approximately 414 hours per week. Bank staff are only used in an emergency. At the last inspection a requirement was made that action needed to be taken to ensure that staff recruitment practices were more robust. This has not been complied with. Four staff personnel files were examined. All contained a completed application form, but did not include a full employment history. Some member of staff had worked in the home/ Cowley Cottage previously, although this was not stated. Not all files contained a reference from the applicant’s most recent employer, references being obtained from work colleagues or friends. None of the files seen evidenced that a formal interview had taken place. Service users are never involved in the recruitment of new staff. All files contained a job description; contract of employment and evidence that police checks had been completed before commencing work in the home. A staff training plan is displayed in the manager’s office. A requirement was made at the last inspection that all staff are provided with training appropriate to meeting the assessed needs of service users. This has not been complied with. The training plan evidenced that many of the staff team have not received mandatory or specialist training. Some mandatory training in first aid, moving and handling and fire safety requires updating. In discussion with staff on duty all said that they would welcome training to carry out their duties more effectively. Staff confirmed that they feel that they are not skilled to meet the specialist physical and emotional needs of the service users, in addition to service users who have specific needs due to behaviours that challenge the service, many of the service users have care needs associated with old age. At the lat inspection a requirement was made that all staff are supervised and that this meets the home’s supervision policy. This has only partly been met and several staff said that they had not received supervision for some considerable time. DS0000011288.V345438.R01.S.doc Version 5.2 Page 23 Staff were observed to be courteous and helpful, carrying out their duties with patience and consideration for the service users. In discussion with staff on duty, staff felt that supported by the deputy manager and their colleagues. Team meetings are held on a regular basis and are minuted; the manager of Cowley Cottage is currently conducting these, during the absence of the manager. Staff handovers take place at the start of each shift and events of the previous shift are discussed. DS0000011288.V345438.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Standards 39 and 42 were subject to requirement at the last inspection. Quality in this outcome area is adequate. The manager needs to be provided with sufficient time to carry out his/her management responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been on maternity leave since June 2007, during her absence the home is being managed by the deputy manager with some assistance from the manager at Cowley Cottage. A return date for the manager is not known. No management hours have been allocated to carry out management tasks and the deputy manager, in addition to managing the home is also one of the three staff on shift. Comments made on a survey DS0000011288.V345438.R01.S.doc Version 5.2 Page 25 completed by a service user’s relative included ‘Cowley House is currently being run by X, deputy manager and helped when necessary by X, manager of Cowley Cottage. The manager of Cowley House is on maternity leave. I would like to praise them for their efficiency and friendly manner in which they run Cowley House. They are both very professional and helpful’. At the last inspection a requirement was made that a report is written on the conduct of the home, following an unannounced visit by a provider representative. This has been complied with. A sample of records relating to health, safety and welfare were examined and found to up to date and well maintained. At the last inspection a requirement was made that all staff are provided with training in moving and handling, infection control and food hygiene. This has not been complied with. Some staff were booked to attend Moving and Handling training in December 2007, this was cancelled at the last minute. DS0000011288.V345438.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 X 2 1 3 1 4 1 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 3 X X 2 X DS0000011288.V345438.R01.S.doc Version 5.2 Page 27 Yes 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 YA2 Regulation 14 Requirement New service users must only be admitted to the home following a full assessment undertaken by people competent to do so. Evidence must be available to demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. Timescale for action 28/02/08 2. YA12 16(1) 3. YA18 12 4. 5. YA22 22 13(6) YA23 Make arrangements for service users to take part in valued and fulfilling activities, which are age, peer and culturally appropriate. Service user must be provided with flexible personal support to maximise their privacy, dignity, independence and control over their lives. All complaints received must be recorded in line with the home’s complaints procedure. All staff must be provided with training safeguarding adults from being harmed or suffering abuse. DS0000011288.V345438.R01.S.doc 28/02/08 07/02/08 07/02/08 28/03/08 Version 5.2 Page 28 6. YA29 13(4) (c) 7. YA33 18(1) 8 YA34 19 9 YA35 18 10 YA42 18 A system for contacting staff within the home, in an emergency, must be put in place. Ensure that at all times there are suitably qualified, competent and experienced persons are on duty in sufficient numbers as are appropriate for the health and welfare of the service users. Recruitment procedures in the home must be more robust to protect service users from possible harm. Previous timescale of 01/09/06 not complied with. All staff must be provided with training appropriate to meeting the needs of the service users. Previous timescale of 30/09/06 not complied with. That all staff are provided with training in moving and handling, infection control and food hygiene. Previous timescale of 30/09/06 not complied with. 28/02/08 07/02/08 14/02/08 28/02/08 28/03/08 DS0000011288.V345438.R01.S.doc Version 5.2 Page 29 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 YA4 Good Practice Recommendations Prospective service users should be able to visit the home on an introductory basis before making a decision to move there and unplanned admissions are avoided where possible. It is recommended that all service users and /or advocates are involving with the drawing up of care plans, agreed, signed and dated. It is recommended that all service users have written confirmation in their terms and conditions about the current fees payable and any additional charges. It is recommended that all staff are supervised and this meets the home’s supervision policy. The deputy/ acting manager should be given sufficient allocated time to undertake his management tasks. 2 3 4 5 YA6 YA5 YA36 YA37 DS0000011288.V345438.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000011288.V345438.R01.S.doc Version 5.2 Page 31 - 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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