Inspection on 27/11/07 for Frank Cowl House

This inspection was carried out on 27th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Frank Cowl House 28/02/07

Frank Cowl House 28/02/06

Frank Cowl House 26/07/05

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 Frank Cowl House Park Avenue Devonport Plymouth Devon PL1 4BG Lead Inspector Antonia Reynolds Unannounced Inspection 27th November 2007 1:00 X10015.doc Version 1.40 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 Frank Cowl House DS0000030792.V345915.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 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 DS0000030792.V345915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frank Cowl House Address Frank Cowl House Park Avenue Devonport Plymouth Devon PL1 4BG 01752 668000 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) Plymouth City Council Susan Debra Wills Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22), Physical disability (5), Physical disability of places over 65 years of age (5) Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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 11,12,13,14,15 and 16 only. Service Users may be admitted aged 50 in the category of PD The home is registered to accommodate a maximum of 22 persons at any one time. 28th February 2007 Date of last inspection Brief Description of the Service: Frank Cowl House is a care home providing personal care and accommodation for twenty-two people, over the age of 50, who may have physical disabilities. The home provides both long stay and short stay care for people. The home does not provide intermediate care. The home is owned by Plymouth City Council and the fee levels are £468 per week. Information about the home and copies of inspection reports can be obtained from the Registered Manager, Susan Wills. Frank Cowl House has been a care home since the 1970s and is located in the Devonport area of Plymouth close to transport routes and local shops. It consists of a large purpose-built, detached, two-storey building. The ground floor is specified for short stay residency and the first floor is specified for permanent residency. All the bedrooms are single and none of them have en suite facilities. There are six large bedrooms on the ground floor specifically allocated for people with physical disabilities. Bathing, showering and toilet facilities, suitable for people with physical disabilities, are available on each floor, close to bedrooms and communal rooms. The home has a lounge room, large dining room, a library and a smoking room on the ground floor and a lounge and a dining room on the 1st floor. The home has a shaft lift, automatic front door and front entrance ramp giving full access to all parts of the building for those people with physical disabilities. There is a call bell system installed throughout the home. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 5 The home does not have a garden but there is an outside seating area at the front of the house and it is situated beside Devonport Park. There is limited parking space at the side of the home and on street parking is available at the front of the building. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of an unannounced visit between 1pm and 5.05pm on Tuesday, 27th November 2007 and a further visit between 1pm and 4.20pm on Thursday, 29th November 2007. The Registered Manager, Sue Wills, was present and available for consultation throughout each visit. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. An annual quality assurance assessment had been completed by the Registered Manager, which contained information relevant to the inspection. Most of the service users were observed during the visits and eleven were spoken with at length. Twenty surveys were sent to service users and ten were returned. Ten relatives were spoken with during the visits. Seven staff members, including one from an agency, were spoken with during the visits and others were observed in the course of their normal duties. What the service does well: The management of the home is excellent and service users are very satisfied with the care provided. The ethos of the home promotes service users’ wellbeing by recognising their rights to independence and autonomy, for example, to retain their own medication. The service users described the staff as being very kind, caring, attentive and respectful. All the service users and their relatives commented on the warm, welcoming, happy and friendly atmosphere in the home. Service users who had apprehensions about coming to stay quickly felt at home. One service user commented “If only everyone received the love and care I get from every one of the staff … the world would be a better world to live in. It’s warm, happy and caring, nothing is too much trouble for any of the staff. It’s a lovely place to grow old in.” One relative commented that Frank Cowl House is the “world’s best home”. The Registered Manager, Sue Wills, is very qualified and experienced. She is liked and respected by service users, their relatives and the staff team. Service users and their relatives were very complimentary about Sue Wills, saying she is “marvellous”, “adorable” and a “lovely lady”. Staff confirmed that they are well supported by Mrs Wills on a day-to-day basis, through regular staff and supervision meetings. Written feedback from staff said that Mrs Wills is “an excellent manager and people person” and “very supportive, kind and caring, will always listen and do her utmost to help if you have a problem”. Mrs Wills is well supported by the staff team, all of whom are competent, experienced and clearly enjoy their work. Staff retention is excellent and there is a very low turnover of staff. This provides the service users with consistency of care and a sense of security because they know all Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 7 the staff members. Service users and relatives were very complimentary about all the staff in the home. Service users said that the meals are very good. They are informed about menus in advance but have the opportunity to change their minds at short notice if they decide they would prefer something else. The home is spacious, well furnished and clean and great efforts are made for people to feel comfortable. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide could be made more ‘user friendly’ and interesting for service users to read. Wash hand basins should be installed in the toilets and shower room that do not have one at present. This is so that people can wash their hands after using the toilet to reduce the risk of infection. The quality assurance system should be reinstated to monitor the quality of care being provided. This system should seek the views of service users, relatives/friends and health/social care professionals who have regular contact with the home. The results of the survey should be made available to current and prospective service users, their representatives and other interested parties and an internal audit should take place at least annually. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 8 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. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 9 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 Outcomes Statutory Requirements Identified During the Inspection Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 4 and 5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The home’s admissions procedure ensures that prospective service users and their relatives/representatives know that the home will meet their needs. EVIDENCE: The pre-admission assessment process ensures that the needs of prospective service users are identified. Service users and their relatives/representatives are welcome to visit the home prior to admission to meet other service users, staff and have a look around the home. The home’s Statement of Purpose and Service User Guide have been reviewed and amended to provide more information for service users. Discussion with the Registered Manager confirmed that each person has a copy of the home’s Statement of Purpose and Service User Guide so that they know what services the home provides. These documents are available for prospective service users, and/or relatives/representatives, to assist them with making a decision about whether this is the care home they wish to live in. A discussion took place with the Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 11 Registered Manager about making these documents more ‘user friendly’ and interesting for service users to read. The home does not admit any privately funded service users, therefore all contracts are between the service user and the Local Authority. These contracts contain details about the terms and conditions of residency. Discussions with service users, relatives, staff and the Registered Manager, as well as observation, show that staff are aware of the needs of the service users. The home does not provide intermediate care. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be assured that they will be treated with the utmost respect, their right to privacy will be upheld and personal and health care needs will be met in the way that service users want and need. EVIDENCE: Service users and their relatives said that they are very well looked after by staff and staff were observed treating all the service users with kindness, consideration and respect. One service user commented that “everything is first class”. Discussions with service users, relatives and staff confirmed that staff work in a person-centred way and personal support is flexible, consistent and meets the changing needs of individuals. Staff respect service users’ preferences and respond sensitively in all situations involving personal care, ensuring it is conducted in privacy. Four service users’ files were inspected and these contained care plans and risk assessments relating to health and personal care needs that are regularly Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 13 reviewed. The Registered Manager confirmed that all the care planning documentation has been reviewed and updated to contain a lot more detail about how the needs of service users should be met by the staff team. Discussions with service users, staff and the Registered Manager, as well as observation, confirmed that personal care is maintained, service users can bathe/shower when they choose to and are encouraged to be as independent as possible. Service users said that the call bell is always answered promptly by staff. Information contained in care plans and discussions with service users, as well as observation showed that service users have access to health care services such as doctors, district nurses, opticians, chiropodists, dentists and occupational therapists. Service users said that they are treated with the utmost respect and dignity and their right to privacy is upheld. Discussions with relatives and staff members, as well as observation, confirmed that staff are fully aware of the need to treat service users with respect and ensure that privacy and dignity is maintained. Staff were observed always knocking on doors before entering private rooms. The home has a pay ‘phone for service users on the 1st floor but service users may also use the home’s ‘phone if they wish to make a private telephone call, for which no financial charge is levied. Service users may also have private telephones installed in their bedrooms at their own expense and people often have their own mobile telephones. With regard to medication, the home’s policy encourages service users to be self-medicating and keep their own medication in their rooms, subject to risk assessment. Service users confirmed that they could keep their own medication if they wished to and are provided with lockable space in their rooms to keep it. Where medication is administered by staff, it is stored securely and a monitored dosage system, pre-packed by the pharmacist, is used for the majority of medicines. There is appropriate storage for controlled drugs and the records are in good order. The home has a small, lockable, refrigerator specifically for storing medicines that need to be kept at low temperatures. The home has a list of homely remedies that may be used for service users if required. The system of administering medication was demonstrated by the Registered Manager and records are kept of the receipt and disposal of medicines. Only designated staff, who receive training from the local pharmacist, administer medication. The home has a copy of the most recent guidance from the Royal Pharmaceutical Society regarding the handling of medication. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The routines in the home are relaxed, relatives and friends can be confident that they are welcomed and social activities are arranged. Dietary needs of service users are catered for with a balanced and varied selection of food that meets service users’ tastes and choices. EVIDENCE: Service users are very positive about the lifestyle at Frank Cowl House. They said that they choose where they spend their day, the times they get up and go to bed and when they want to have a bath/shower. Service users and their relatives confirmed that visitors are welcome at any time and they particularly enjoy the interaction and conversation with staff. Visitors spoken to said they may visit when they wish, are always welcomed by friendly staff and able to make themselves a drink in the small kitchen on the first floor, should they wish to. Service users may bring small caged pets with them into the home and other pets, such as dogs and cats, may be permitted, with the agreement of the management team. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 15 Discussion with service users, relatives and the Registered Manager confirmed that the home provides various activities for service users to participate in. These include exercise classes, darts, bingo, quizzes, bowls, board/spelling games and social evenings/events. Some activities are provided by external facilitators, such as a reminiscence group, musical entertainment and computer skills. Service users confirmed that they have the use of a minibus for outings and they have trips out to The Hoe, the Barbican and Dartmoor. They said that a trip has been arranged to see the Christmas lights in Plymouth and the home is hosting a Christmas Fayre in the immediate future. Some service users go out regularly with their families and friends. All the service users said they liked the food and that anything they ask for is provided. Service users are asked what they would like for each meal the day before but also have the opportunity to change their minds at short notice if they decide they would prefer something else when they see the meal being served. Service users said that they may eat meals either in their rooms or in the dining rooms and discussions with several people confirmed that they may have whatever they like for breakfast, cooked or otherwise. Fresh fruit is always available and service users may help themselves. Service users and the Cook confirmed that special diets are catered for, such as gluten free, diabetic, or vegetarian and, if required, nutritional plans are in place that follow advice given by doctors and dieticians. The home has facilities where service users and their relatives can prepare their own drinks and snacks if they wish to, rather than using the main kitchen. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that any concerns or complaints are treated seriously and that they will be protected from abuse. EVIDENCE: The complaints procedure and appropriate information is posted on the notice boards in the home and contained in the Service User Guide. Service users and their relatives said that they know how, and to whom, to make a complaint should they need to. Service users said that they had confidence in the Registered Manager and the staff team to resolve any issues as soon as they arise. However, service users also said they have no complaints about the home or the care they receive. Discussion with the Registered Manager confirmed that all comments or complaints are investigated, no matter how small, and improvements made if required. Staff members spoken with said that all staff are expected to attend training related to the protection of vulnerable adults and the Registered Manager is clear about the procedure to follow if necessary. Written feedback from fourteen staff members confirmed that they are aware of adult protection procedures. There is a visitor’s book in the front hallway to record dates, times and names of all visitors to the home. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The service users live in a pleasant, well-maintained home that is comfortable, warm and clean. EVIDENCE: All private and communal rooms are attractively decorated, the furnishings are of a good quality and the home is well maintained. Service users and relatives confirmed that the home is comfortable and always warm and clean. The home is adapted for service users with mobility difficulties and these adaptations include an external ramp to get into the house, an automatically opening front door, a passenger lift that has access to the 1st floor, adapted baths and showers, grab rails, raised toilet seats and rails and lifting hoists. The home has several communal rooms for service users on both the ground and 1st floors. On the ground floor there is a dining room, two lounge rooms, a Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 18 sunroom and a smoking room. On the 1st floor there is a lounge and a dining room. The smoking room is closed between midnight and 6am for cleaning. Other communal rooms are available to the service users at all times. There is a call bell system installed throughout the home. Each service user has a single bedroom, all of which contain wash hand basins. None of the bedrooms have en suite facilities. The bedrooms are located on both floors of the building and there is a shaft lift between them. Bedrooms are individually furnished and contain many personal possessions. The type and quantity of furniture varies dependant on the wishes and needs of service users. All the bedroom doors have locks fitted and service users may have a key if they wish. All the bedrooms contain a lockable safe and service users are offered a key or a numerical code to lock it. All the bedrooms are well decorated, comfortably furnished and personalised with service users own pictures and ornaments. Bathing, showering and toilet facilities are available on each floor, close to bedrooms and communal rooms. Three of the individual toilets, as well as a level access shower room, do not contain wash hand basins and this may increase the risk of infection if people are not able to wash their hands after using the toilet. Service users said they are satisfied with the laundry arrangements and none of the service users spoken with had experienced any items going missing or being damaged. The home has a sluice room on each floor and a laundry on the ground floor. Infection control practices and procedures ensure that any risks of infection are reduced or eliminated and there were no offensive odours in the home. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 19 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users are assured that they will receive care from an experienced, competent and caring staff team. Recruitment practices protect vulnerable service users. EVIDENCE: Observation and discussion with service users, relatives and staff confirmed that the staff team are respectful, polite, attentive and responsive to service users’ needs. Service users described the staff as very kind and caring and confirmed they responded promptly to requests for assistance indicating that there are sufficient staff to meet the needs of those currently living in the home. There are usually three or four care staff on duty during the day, three during the evening and two waking night staff. In addition, one of the Assistant Managers sleeps in the home at night. The Registered Manager and staff confirmed that staffing is flexible depending on the needs of the service users and agency staff are used if required. As well as the care staff, the home employs administrative, catering, domestic and maintenance staff. Staff turnover is extremely low and many staff members have worked at the home for several years, thereby providing consistency for the service users. The home has not employed any new staff since the last inspection in February 2007. An agency staff member confirmed that the home provides a brief Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 20 induction for agency staff that includes emergency procedures and fire safety awareness. Each staff member has a personal training and development programme and there is ongoing training for all staff members. This includes topics such as health and safety, first aid, medication, manual handling, fire safety, food hygiene, hazardous substances, infection control, diabetes, continence care, sensory impairment and mental health, as well as National Vocational Qualifications (NVQs). Discussion with the Registered Manager, as well as documentation, confirmed that 64 of the care staff have achieved a National Vocational Qualification at level 2 or above, which is an excellent achievement. Recruitment processes are robust in that two written references are obtained as well as a Criminal Records Bureau (CRB) check and the Registered Manager confirmed that new staff are supervised until satisfactory references and checks are obtained. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 21 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users live in a very well managed home and benefit from an open and inclusive ethos. The management and staff team strive to provide a stimulating, safe environment where service users are respected and rights are upheld. EVIDENCE: The Registered Manager, Sue Wills, has many years experience of working in care homes and has been managing this home for approximately four years. She is well qualified to do so as she has achieved a Bachelor of Arts (Honours) degree in Social Policy, a level 4 National Vocational Qualification in Health and Social Care and has completed a management qualification, the Registered Manager’s Award. She undertakes periodic training to update her skills, Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 22 knowledge and competence for example, recently attending a seminar about the new Mental Capacity Act that is due to come into force this year. Service users and relatives were very complimentary about Mrs Wills’ management skills and her acceptance of service users’ different needs. Service users said that they feel safe and secure in their home and that the home is well managed. Service users and relatives were very complimentary about Mrs Wills, saying she is “marvellous”, “adorable” and a “lovely lady”. Staff confirmed that they are well supported by the Registered Manager on a day-today basis, through regular staff and supervision meetings. Written feedback from staff said that Mrs Wills is “an excellent manager and people person” and “very supportive, kind and caring, will always listen and do her utmost to help if you have a problem”. The service users or their families/representatives manage their financial affairs, although the home does manage small amounts of spending money on behalf of service users. The records relating to spending money of service users was checked and found to be correct, with up to date records kept. A discussion took place with the administrator about ways of simplifying the existing system. Each service user has been provided with a small safe in their room that can be locked with a key or a numerical code. Where service users need assistance staff can access the safe with a key that they must sign for. Health and safety practices are satisfactory in that equipment is maintained in good working order and staff receive training in health and safety, fire safety, first aid, food hygiene, infection control, hazardous substances and manual handling. Inspection of the fire logbook indicated that regular tests/checks of the fire alarm system/equipment are carried out. The Cook keeps records of fridge/freezer and cooked meat temperatures and there was a cleaning rota available in the kitchen. The Registered Manager confirmed that window restrictors are fitted to all windows above the ground floor, the radiators are guarded and all hot water outlets accessible by the service users are regulated, to reduce the risk of burns and scalds. The home records all accidents and the Registered Manager monitors this to identify the reasons, check for risk areas and look for any patterns. If required, reviews of a service user’s care will be arranged and health and social care professionals consulted. The home has a quality assurance system in place however this is not being used as an ongoing process to monitor the quality of care being provided. The system needs to be reinstated to actively seek the views of service users, relatives/friends and health/social care professionals who have regular contact with the home. The results of the survey should be made available to current and prospective service users, their representatives and other interested parties and an internal audit should take place at least annually. Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 2 X 3 3 X 3 Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP21 Good Practice Recommendations Wash hand basins should be installed in the toilets and shower room that do not have one at present. This is so that people can wash their hands after using the toilet to reduce the risk of infection. The quality assurance system should be reinstated to monitor the quality of care being provided. This system should seek the views of service users, relatives/friends and health/social care professionals who have regular contact with the home. The results of the survey should be made available to current and prospective service users, their representatives and other interested parties and an internal audit should take place at least annually. 2. OP33 Frank Cowl House DS0000030792.V345915.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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