Inspection on 26/07/05 for Frank Cowl House

This inspection was carried out on 26th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Frank Cowl House 27/11/07

Frank Cowl House 28/02/07

Frank Cowl House 28/02/06

Frank Cowl House 22/02/05

Frank Cowl House 19/08/04

Frank Cowl House 11/02/04

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

CARE HOMES FOR OLDER PEOPLE Frank Cowl House Park Avenue Devonport Plymouth PL1 4BG Lead Inspector Brendan Hannon Announced 26 July 2005 th 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 Older People. 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. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Frank Cowl House Address Park Avenue, Devonport, Plymouth, Devon, Pl1 4BG 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) 0752 668000 Plymouth City Council Susan Debra Wills Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21), Physical disability (5), Physical disability of places over 65 years of age (5) Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1st Floor - To be used for long term residential care only Ground Floor - To be used for short term residential care only Service Users with the category PD and PD(E) to be accommodated in room numbers 12,13,14,15 and 18 only. Service Users may be admitted aged 50 in the category of PD One extra room to be registered to long stay accommodation - total 11 beds Date of last inspection 22/02/05 Brief Description of the Service: The home is a large pupose built detached building, built in the 1970s, located in the Devonport area of central Plymouth, and managed directly by Plymouth City Council Social Services Department. A full range of amenities and facilities are within either a walk or short bus ride of the home. The home can accomodate up to twenty one residents over two floors. The ground floor is specified for short stay residency and the first floor is specified for permanent residency. The building has both physical disability accessible bath and shower facilities. It also has a shaft lift, automatic front door and front entrance ramp giving full physical disability access to all parts of the building. However six large appropriately shaped rooms on the ground floor are specifically allocated for physical disability use. There are two lounges and a dining room on each floor. In addition a smoking room has been created on the ground floor. In total the home has seven communal rooms of various sizes and uses. Being in central Plymouth the home does not have a garden area but there is an outside seating area to the front of the building. The home is located beside the large parkland area of Devonport Park. All the accomodation in the home is in single bedrooms. None of the bedrooms in the home have ensuite toilet facilities. The service offered by the home is primarily for older people with some mobility difficulties. The residents have a mixed range of abilities and there is an active community amongst the permanent residents group. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. Preparation for the inspection included, analysis of the pre inspection questionnaire, the previous inspection reports and resident and relative comment cards. An inspection plan was developed from this information. The inspector was in the home for 7.0 hours from 9.45am till 4.30pm. The inspector spoke to five of the twenty residents with particular attention given to two residents whose care was looked at closely. The registered manager of the home, Sue Wills, was spoken to at length. Care plans and various records, including medication administration records, staff/employment records, and health and safety records, were inspected. Some policies and procedures were also discussed. What the service does well: The home provides good information about the service to all potential new residents and their representatives. This enables potential residents to make an informed choice whether to use the service. The home was commended in this report for the quality and thoroughness of the pre admission assessments carried out for both long and short stay residency. This thorough assessment enables the service to thoroughly meet the needs of all new residents. The excellent level of healthcare support facilitated by the home helps to maintain the residents in good health and was commended in this report. The home was also commended for the excellent quality of medication administration being carried out by the service for both long and short stay residents. Personal care is well delivered to all the residents and there was a good standard of cleanliness and hygiene in the home. The residents’ quality of life is maintained through support for residents’ varied leisure and social activity both in and outside the home. The residents’ nutritional needs are met and residents receive enough good food. The service benefits greatly from the building being purpose designed, built, and fitted with appropriate facilities to meet residents’ physical disability needs. Plymouth City Council has substantially invested in the quality of the living environment and the building is well maintained. The quality of the décor throughout the communal areas and bedrooms was very good. Resident’s needs are met by an adequate number of competent, qualified, properly vetted and trained staff. There is an effective open system of management in the home provided by competent, well trained managers. The staff are being professionally supervised to ensure that the existing good quality of care continues to be provided to the residents. The quality assurance system in use in the home is good and continues to be creatively improved by the management. The service was commended for the Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 6 quality assurance system. This system will help the service to identify where further improvements can be made to benefit the residents. In general health and safety is well maintained providing the residents and staff with a safe environment to live and work in. 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. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5 The home provides good information about the service to all potential new residents and their representatives. This enables potential residents to make an informed choice to use the service. The service assesses the potential residents needs before admission and recognises the needs that it can meet. EVIDENCE: Both the Service Users Guide and the homes Statement Of Purpose were available. There was clear well presented information in the Service Users Guide. This information enables potential residents to make an informed decision about whether to use this service. The registered manager was advised to ensure that the different facilities/services available to short stay residents are explained in the service users guide so that the short stay residents are well informed as well as the permanent residents. The home rarely accepts emergency admissions. Even with short stay admissions the service usually insists that there are a few days available to assess whether the home is appropriate to meet the potential resident’s needs. The unit is using its own ‘screening tool’ to assess all potential short stay residents. If there are any queries after this assessment has been carried out then a home visit is arranged to gather further information. This thorough system ensures that any potential residents needs can be met by the service. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 9 Long stay admissions are assessed through information either from the SAP (Standard Assessment Process) or from the social services core assessment. This written information is then added to by assessment either at the persons present accommodation or during their visits to Frank Cowl House. The home is commended in this report for the quality and thoroughness of the pre admission assessment process for both long and short stay residency and the service has exceeded standard 3. Residents and care staff were observed and were spoken to during the inspection. Through this observation, looking at care plans, and looking at records there was good evidence to show that the residents’ needs are being met. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 The delivery of resident’s care is good but is hampered by limited care planning and resident risk assessment. Improvements in these areas will further support the delivery of consistent, high quality care to the residents. Healthcare support and medication administration within the home are very good, which helps to maintain the health of the residents. EVIDENCE: Resident’s care plans were sampled. All the residents had a care plan and individual risk assessment in place. The care planning system is clear, practical and easy to understand. The care planning is separated into the two groups of permanent and short stay residents. The information held in the care plan document was too brief and did not cover all of the resident’s needs. For example, mental/emotional state and social/leisure needs were identified verbally by the registered manager as existing resident’s needs, but these sections are not available within the care plan format and therefore these needs had not been documented. There was not enough detailed information particularly on the resident’s assessed needs and at times the directions to staff as to how to meet the identified needs had been inappropriately placed in the individual risk assessment rather than within the care plan. The registered manager stated that all care plans are reviewed Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 11 monthly. A record of each monthly review should be kept where no change has been made to the care plan information. The registered manager was also advised to document any unused facility or service, e.g. none of the existing residents use their individual bedroom door keys either through their choice or because of unmanageable risk. The registered manager was also advised to document any function where the resident is being supported by the service by agreement, e.g. administration of personal money or management of smoking materials. When a more detailed care plan has been developed for each resident the quality of care support will be further improved and this should therefore improve the resident’s quality of life. There was good evidence of the involvement of healthcare professionals such as the GPs and district nurses in the support of the health of the residents. There is a treatment room available, which is used only by the district nursing service. There is a contractual arrangement between the district nursing service and the home to provide a healthcare screening service for all short stay residents when they are admitted. In addition the district nursing service holds a weekly clinic at the home for the benefit of all the residents. There is also a contractual arrangement with a local GP to support the general health needs of all the short stay residents while they are at the home. The excellent level of healthcare support facilitated by the home helps to maintain the residents in good health. The home is commended for the quality of the healthcare support available to the residents, and standard eight has been exceeded. Medication is very well managed in the home. There are two specific medication administration storage rooms in the home, one for short stay and one for long stay residents. The home uses a monitored dosage blister pack system supplied by a local pharmacy. Both the quality of storage and recording for both ordinary prescribed and also controlled drug medication was excellent. There was an excellent procedure in place for support of medication administration for the short stay residents. This ensures that all of the resident’s prescribed medication is administered comprehensively and correctly by the service within the first few hours of admission to the short stay service no matter what the condition of the medication brought to the unit. The home is commended for the quality of medication administration being carried out by the service and standard 9 has been exceeded. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 The home supports residents’ leisure and social activity both in and outside the home. The residents’ nutritional needs are met and residents receive enough good food. EVIDENCE: Evidence of the activity being participated in by residents is provided through the individual daily records, which are made up of separate AM, PM and night entries. These records were adequate. The residents’ daily records describe the quality of each resident’s day and any contact with friends and family from outside the home. Indoor activities include reminiscence groups, sing along sessions, movement to music sessions, computing classes and Bingo. The home will soon be receiving its own computer for residents to use. Some residents regularly enjoy going out unaccompanied. Others go out with members of staff and to church groups. This activity maintains the residents quality of life. Resident’s food likes and dislikes are found out by the service. A four-week menu plan is in place but the food actually prepared is not rigidly dictated by this plan. There is a record kept of the food actually provided but this was not comprehensive and the registered manager was advised to maintain this record fully. This record will help to ensure that the food provided is nutritionally balanced and wholesome and will therefore help to maintain the health and quality of life of the residents. The décor in the two dining rooms gives a pleasant environment to take meals in. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 13 Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents and the public have good access to the complaints procedure and residents are protected from abuse. EVIDENCE: There is a good complaints procedure, which is distributed to residents and is clearly displayed in the home lounges and lobby area. The contact details for the CSCI are given in this procedure. The home has all the required adult protection policies in place and the homes management has attended adult protection training. The homes staff are now also beginning to attend this training. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The residents have a good quality of life within the home because the quality of the environment and facilities in the building is maintained at a good standard. EVIDENCE: A complete tour of the building was made during the inspection. The service benefits greatly from the building being well designed and built specifically as a care home in the 1970s. The building has wide corridors and many well proportioned rooms which make it well suited to provide support for extensive physical disabilities. The building has been well maintained and in general only a few minor faults were found. Plymouth City Council has substantially invested in the quality of the living environment. The quality of the décor throughout the communal areas and bedrooms was very good with no part of the building being in immediate need of either redecoration or carpeting. Permanent stay residents commented on how they had been consulted on the colour scheme for the redecoration of their rooms. The permanently occupied bedrooms have been personalised by the residents and generally facilities in the bedrooms are good. All the furniture in both the communal areas and in Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 16 the bedrooms was generally in a good state of repair. By taking out built in furnishings in favour of free-standing wardrobes some of the smaller rooms in the home have successfully had their useable space increased. The residents said they were happy with the quality of the environment in the home. Some issues were noted during inspection of the building. All the bedrooms have overdoor corridor windows which let light from the corridors into the bedroom at all times of day and night, although the corridors are only dimly lit during the night. Residents should be given the opportunity to sleep in a dark room. The bedroom overdoor corridor windows should be blacked out and only uncovered when individually requested by residents. In one bedroom, which was converted from communal space to a bedroom some years ago, a wash hand basin has not been fitted and a communal door connecting with another unused communal area has not been removed. The service is required to address this issue. Both the first floor enclosed sluice and the shower on that level are not functioning properly due to problems with the hot water pressure due to the ground floor boiler being unable to sustain adequate pressure to the first floor. Though both facilities are not vital to the immediate wellbeing of the residents this issue should be addressed to bring these useful facilities back into full operation. The laundry facility was of good quality and was clean and tidy. The COSHH chemicals were locked away. The home was clean and hygienic and there were no offensive odours anywhere in the building. While either of the two enclosed sluices is unuseable it will be necessary to carry out open sluiceing in the home. Therefore it is recommended that all the necessary protective equipment is provided for the staff involved in this procedure and that this change should be added to the infection control policy and procedure. Considerable investment has been made in creating a safer environment in the home. The registered manager stated the following. All the radiators and exposed hotwater pipes have been covered to eliminate the risk of pressure burns from contact with a hot surface. All the window openings above ground floor level have been limited to eliminate any risk of falls from windows. All of the hot water taps at baths, showers and sinks available to residents have been fitted with hot water temperature limiting control valves. As a result of this investment the residents benefit from a safer environment. The smoking room, located on the ground floor, is a pleasantly decorated former bedroom. It was noted both during this inspection, and during the last regulation 26 visit, that the smoking room may at times have a high concentration of cigarette smoke. It is recommneded that there is increased ventillation from this room to ensure that the smoke does not make its way into the rest of the smoke free building. The residents enjoy a high quality of facilities, well decorated communal and personal spaces and a safe environment. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 17 Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Resident’s needs are met by enough competent, qualified, properly vetted and trained staff. EVIDENCE: Both the pre inspection questionnaire and the registered manager stated that 65 of the care staff have achieved an NVQ2 level care qualification. The management team, made up of the registered manager, three assistant managers and three relief managers, are highly experienced and well qualified. The residents are better cared for because the staff team is trained and competent to deliver care. There is an adequate level of staffing detailed in the staffing record to meet the service users needs. The basic staffing level excluding managers is four care staff AM and PM, two awake staff and a sleeping in assistant manager at night. The staff were seen throughout the inspection to be relaxed, patient and helpful when assisting the residents. The registered manager stated that Criminal Records Bureau (CRB) clearances and checks of the Protection Of Vulnerable Adults (POVA) register had been received for all members of staff. The residents can be assured that they are secure and safe when left in the care of any of the staff. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,37,38 The management of the home is effective and continues to ensure that the needs of the residents are met. EVIDENCE: Both the registered manager and one of the three assistant managers have achieved the Registered Managers Award. Throughout the inspection an open supportive and friendly management approach was seen in the home. There is an established system of supervision under way. This regular supervision helps to monitor and improve staff practice and training and therefore improve the care received by the residents. The quality assurance system includes giving questionnaires to all short stay residents at the end of their stay. A new ‘evaluation’ quality assurance system has recently been developed at Frank Cowl House and will be ‘rolled out’ to the other Plymouth City Council (PCC) homes following its successful develoment at this service. Information is gathered from questionaires and other records to Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 20 establish the success of the service in delivering the best outcomes for residents. For example there is evidence to show that longer periods of respite care reduces the likelihood of in patient hospital stays. The service had already exceeded the requirements of standard 33 for quality assurance and the new system of evaluation has only added to this level of quality. Good quality asssurance will help to promote continuous improvement in the service to meet residents needs more effectively. Residents personal money is being deposited and withdrawn from a residents bank suspense account. The type of general pooled bank account in use is not in the best interests of the residents and is no longer accepted under the Care Homes Regulations. The service is required to establish new systems in line with the Care Homes Regulations. Residents personal money is also pooled together within the home which does not comply with standard 35. The service was required to individualise this system so that all residents money is handled seperately. PCC is working to change these systems uniformly in all their care homes. These changes will allow the service to appropriately support residents to manage their own money. The fire protection system is generally well maintained. Maintenance checks are being carried out. However the home has not maintained the frequency of fire protection training for staff that is stated within the homes fire protection policy. The management of the service should implement measures to ensure that six monthly fire training is maintained for all the staff. All the communal and bedroom self closing doors have been fitted with appropriate hold open devices so that residents can move about freely in the home while being kept safe in the event of fire. The homes kitchen was being well managed and was clean and tidy. Some of the fridge and freezer temperatures were sampled and these were appropriate. Good clean food store rooms were seen. Gas and electrical appliances are being routinely serviced and checked. These good health and safety practices reduce any unreasonable risk affecting residents or staff to an acceptable level. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 4 x 2 3 3 3 Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 22 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 35 Regulation 20 Requirement Residents personal money must not be paid into a pooled bank account. Residents pesonal money must not be pooled within the home. Bedroom no.17 must have a washhand basin fitted and the intervening door into the adjoining unused area must be permanently removed. Timescale for action 01/04/06 2. 24 23 26/11/05 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. 2. 3. 4. Refer to Standard 7 20 24 26 Good Practice Recommendations All the residents should have a comprehensive and detailed care plan and individual risk assessment. A record of monthly reviews should be kept. Additional external ventillation should be put in place in the smoking room to ensure that cigarette smoke is ventillated out of the building. All the overdoor corridor bedroom windows should be blacked out and only uncovered when individually requested by residents. The supply of hot water to the first floor should be assisted in order to allow the first floor enclosed sluice and walk in D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 23 Frank Cowl House 5. 38 shower to return to full use. Till enclosed sluicing facilities are available on each floor all necessary protective equipment should be made available to staff engaged in open sluicing. Ongoing training in fire protection for staff should be maintained at the six monthly frequency stated as the homes policy. Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Frank Cowl House D52-D04 S30792 Frank Cowl House V226821 260705 Stage 4.doc Version 1.40 Page 25 - 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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