Inspection on 28/02/07 for Frank Cowl House

This inspection was carried out on 28th February 2007.

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

The inspector found 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 28/02/06

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 Helen Tworkowski Unannounced Inspection 10:20 28 February 2007 th 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.V311055.R02.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.V311055.R02.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.V311055.R02.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 2006 Date of last inspection Brief Description of the Service: The home is a large purpose built detached building, built in the 1970s, located in the Devonport area of 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 accommodate up to twenty-two 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 three lounges and a dining room on the ground floor and one lounge and a dining room on the first floor. One of these lounges is used as a smoking room. 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 accommodation in the home is in single bedrooms. None of the bedrooms in the home have en suite 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. The weekly fee for Frank Cowl House is £380 per week. This does not include hairdressing, chiropody, newspapers, stamps, and telephone calls. There is a Statement of Purpose and Service Users Guide, there are available Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 5 to Service Users in the office, or on notice boards around the home. Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included site visits to Frank Cowl House on 28/2/07 (10.20 am to 5.30pm) and 1/3/07 (10.20 am to 3.45pm). As part of this inspection the inspector looked around the building, spoke with the manager and care staff, and met with the District Nurse. The Inspector looked specifically at the care of 4 people staying at Frank Cowl House, and spoke with 9 people about the care and support they received. The inspector ate a meal with Service Users, looked at the medication system, and records relating to health and safety and records relating to employment. In addition a “Pre-Inspection Questionnaire” was received prior to the start of this inspection. Surveys were sent to 13 members of staff eight were returned. Surveys were also sent to 17 service users, 11 were returned. The Inspector also contacted three social service care managers, one responded to the contact. What the service does well: What has improved since the last inspection? A fan has been fitted to the smoking room, though this is now in need of cleaning. This was fitted to try to extract some of the smoke from the atmosphere. Each Service User now has a safe in their own room, with a key or a pin code number. A system has been set up to ensure that individual service users Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 7 money is properly accounted for. However an error was found in the one account looked at, indicating the need for an auditing system. One bedroom was identified in the last inspection as not having a sink. All bedrooms now have sinks. The “fan lights” glazed areas over bedroom doors, are now covered if service users feel that light from the corridor will disturb them. At the last inspection a problem was identified with the hot water system, this has now been rectified. What they could do better: Service Users feel very well cared for, however the documents that agree and communicate an individual’s needs lack detail, and in some cases assessments of needs are not received prior to a move to Frank Cowl House. This could lead to needs being missed or not met in a consistent manner. There is also no opportunity for Service Users to confirm that they would like to be cared for in a particular way. Service Users are not always given information about what to expect at Frank Cowl House before they move. This can be an additional unnecessary worry for people at what can be a very difficult time. Individual risk assessments that should identify how risks will be managed, relate to general risks. Each person is different and the way that risks may be managed can be different- for example in relation to falls, or vulnerability if they wish to go out alone. Each Service User could been offered a key to their bedroom, this is not done. Frank Cowl House has a good system for managing medication, however where service users self medicate there is no risk assessment of this, to ensure that Service Users have the skills and support they need. The Fire Risk Assessment does not specify how often staff should be trained, all staff should be trained to the standard that is set in the Fire Risk Assessment. One of the showers had water that was hot enough to burn someone if turned to a maximum temperature. All showers and baths should have water that is regulated so that this risk is eliminated. Frank Cowl House DS0000030792.V311055.R02.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.V311055.R02.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.V311055.R02.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): 1, 2, 3, and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The system for assessing service users gives little time for the care home to ensure that they can meet an individuals needs before they move. Service Users are not always provided with sufficient information about the home before they move. EVIDENCE: The Inspector was given a copy of the recently amended Service Users Guide and Statement of Purpose during this inspection. These documents provide information about what Service Users can expect from living at the home, and should include terms and conditions. The Care Home regulations specify what should be in the documents. The Statement of Purpose and the Service Users do not contain the necessary information set out in the regulations- for example the Service User’s Guide does not contain information about the terms and conditions or the fee payable. The Statement of Purpose contains not information about the number and sizes of rooms. These documents need to be amended and copies forwarded to the Commission. Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 11 The Inspector asked the Manager about whether these documents were available to Service Users, and she confirmed that they were available in the office or on the notice board. Some of the people in the home are in wheel chairs and might find it difficult to access these documents. The managers said that a Service Users Guide used to be provided to each person in their room, however this practice had ceased. It was agreed with the Manager that this was good practice and should be re-instated The Inspector asked two of the service users what they knew about the home before they moved, neither had been given any information about what they might expect. One person said that she had been very scared about the move, however her fears had been quickly overcome, once she had arrived at Frank Cowl House. All prospective service users and their representatives should be given sufficient information about the service at Frank Cowl House, so that they can make an informed decision about a move. The Inspector asked to see copies of the contracts or terms and conditions provided to Service Users. These documents would agree what would be provided by the service and what would be expected from the Service User. The Inspector was told that no terms and conditions were provided to Service Users. Service Users should know what service they are buying or is being purchased on their behalf, they should know any limitations or restrictions on living at Frank Cowl House. The assessments of two people who had recently moved to Frank Cowl House were looked at. The Social Services Care Manager for the individuals had completed these assessments. The Manager confirmed that these documents were not always received prior to a person moving to the home, staff however did have a phone discussion about the persons needs. The Care Home regulations are clear that the Care Home should receive in writing the assessment, so that the Registered person can make an informed decision about whether needs can be met. Also the Registered Person must ensure that they confirm in writing to the Service User or their representative that, based on the assessment, that they are able to meet the needs of that individual. Having a written assessment, in good time, ensures that the care home can ensure that staff not only know the needs of the individual, but ensure that any additional equipment or staff training is in place. Frank Cowl House DS0000030792.V311055.R02.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): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users social and health care needs are generally well met, however the poor records relating to care mean that there is a risk of needs being missed or not consistently met. There are generally good systems in place for the management of medication. Service Users are treated with respect. EVIDENCE: The inspector spoke with Service Users about the care they needed and they were clear that they were very satisfied with the help that they received. One person said “The care is fantastic…they actually care for me as an individual, not one of the herd”. When the inspector asked senior staff about service user needs they were aware of what individuals needed. All 11 service users who responded to the survey said that they always or usually received the care they needed. Each person who lives in a care home, must have a plan of their care (or Service User plan) which details, based on the assessment, how these needs are to be met. The documents at Frank Cowl House are very brief and contain Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 13 minimal information. They do not reflect the needs of the individuals. For example from other information on a file it was clear that one individual had an eye condition that meant that he/she lost his/her central field of vision. This was not mentioned in the care plan, nor were there any directions to staff as to how this might affect the person or how staff might best support this individual. Other Service User plans stated that individuals needed assistance to wash and dress, however there was no information as to what assistance they needed. A number of people at Frank Cowl House have diabetes whilst this was mentioned in the care plan; there was no specific direction in relation to the management of this condition. The Inspector spoke with the District Nurse who visits Service Users who have medical or nursing needs. She confirmed that Staff follow the advice that they are given and call appropriately for support from the nursing service. She also commented that people are well treated at Franck Cowl House, they do the “extras” for people. There were no individual risk assessments on file, or comprehensive moving and handling assessments. These documents are part of the process of ensuring that service users and staff are not exposed to unnecessary risk. The standard of care provided appears to be of a good standard, however the documents that should support and direct this care are inadequate. These documents are important, they are one way of ensuring that staff are providing care in a consistent manner, and they should be shared and agreed with Service Users, so that they can agree how they wish their care to be provided. The poor standard of Service User plans and risk assessments was identified at the last inspection a year ago and a requirement was made, it has not been met. A “monitored dose” system is used to manage most of the medication. This is pre-packed by the pharmacist. The Inspector was shown the medication system by one of the staff who dispense medication. There are good records of medication administered by staff, including controlled drugs. The system is well organised and in good order. The member of staff explained how the local pharmacist is involved in training staff and ensuring that staff are competent. Some of the Service Users administer their own medication; this is something that the Commission promotes, providing that appropriate risk assessments have been made. No such risk assessments had been made. Through out the inspection the Inspector noted that staff knocked on Service Users doors, before they entered, and Service Users said that they were treated with respect. The Inspector observed numerous positive interactions between service users and staff. Many Service Users commented on the very happy and friendly atmosphere at Frank Cowl House. Frank Cowl House DS0000030792.V311055.R02.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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are encouraged to make choices about their daily lives at Frank Cowl House. The home provides a good standard of meals, well cooked and nutritious. EVIDENCE: The Service Users who spoke with the Inspector said that they could get up and go to bed when they choose, and that they had choices about how they spend their time and about meals. One service user has a small dog, staff at Frank Cowl House had understood the importance of this pet to the individual, and had made the effort for the arrangements for the dog to join it’s owner at Frank Cowl House, and continued to provide support for both. The home provides some activities such as music sessions, bingo and other activities. Some of the Service Users commented in the survey that the “could do with some more activities to keep our minds going”. This was discussed with the manager who confirmed that this was an area they had identified where improvement could be made. Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 15 The Inspector ate a meal with the service users on the second day of the inspection. The meal was well cooked and presented. Nine of the eleven service users responding to the survey said that usually or always liked the meals; the other two people said that they usually enjoyed the meals. The dining rooms are well furnished and care and thought had been taken to make them pleasant rooms, there were fresh flowers on each table. Service Users are provided with a choice of meals- and there is fresh fruit available. There is a kitchen area on the ground and first floor, where service users can make their own drinks if they are able to, or where Occupational Therapists can observe Service Users, to ensue that they have the skills to use at home. The manager said that visitors are welcome to use the small kitchen to make drinks. Frank Cowl House DS0000030792.V311055.R02.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users can be confident that their concerns and complaints will be taken seriously. EVIDENCE: The Commission has not received any complaints about Frank Cowl House. Ten of the eleven service users who responded to the survey said that they always knew who to speak to if they were not happy and how to make a complaint. The home has a complaints procedure and this is displayed on notice boards. The Manager said that they had no complaints had been received since the last inspection, and had evidence that previous complaints had been appropriately managed. All but one of the staff responding to the staff survey said that they were aware of adult protection procedures. The person who did not know is not directly involved in providing care. There is information in the office about how concerns of abuse should be dealt with. Frank Cowl House DS0000030792.V311055.R02.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): 19, 20, 21, 23, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users at Frank Cowl House can be assured that their accommodation is warm, comfortable and well maintained. EVIDENCE: As part of this inspection most of the rooms in the home were seen. The lounge areas are clean and comfortable. They are not large rooms and therefore are less institutional being domestic in scale. All of the bedrooms are of a good size, and well decorated and comfortable. Each bedroom had a door lock, but service users told the inspector that they had not been offered a key. Each bedroom does however have a lockable safe and Service Users are offered a key or pin code to this. Effort had been taken to make the bathrooms homely and domestic in feel. It was noted that two bathrooms did not have door locks; all bathrooms and toilets must have appropriate door locks. As part of this inspection the Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 18 temperature of water in some baths and showers was checked. The water in a shower was found to be excessively hot, the manager was aware of this, and there was a record of the excessive temperature in the checks that are made. Service Users safety could be put at risk by this hot water. The Registered Manager arranged for the shower to be put out of use before the end of the inspection. All hot water in baths and showers must be thermostatically regulated so that there is no risk of scalding. The windows throughout the home are double-glazed and all have a device on them to stop them being opened wide. Those on the ground floor have, in addition, been fitted with a device to stop intruders gaining entry. There is a smoking room on the ground floor, and a requirement was made at the last inspection that the ventilation be improved in this room. An extractor fan has been fitted in this room, however the fan was in need of cleaning. The home is clean and there is a laundry area and a sluice room. All of these areas are clean and there were no offensive odours. Nine of the ten service users who responded to the survey said the home was always fresh and clean. Frank Cowl House DS0000030792.V311055.R02.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): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are assured that they will receive care from the experienced competent staff. EVIDENCE: The Inspector looked at the rota for staff on duty. The rota showed that there were always sufficient care staff on duty, and also senior staff are on duty 24 hours a day. In addition to care staff there are domestic and kitchen staff. The pre-inspection questionnaire shows that 60 of staff have NVQ2 or above, this is above the 50 level set in the National Minimum standards. As part of this inspection staff training records were looked at. Not all of these records were up to date, and Registered Manager explained how they were changing the system to provide a better overview. The records of staff training seen show that staff have received training to enable them to do their work. Plymouth City Council had employed no new staff, to work at Frank Cowl House, since the last inspection. Staff had been transferred from other Care Homes, and therefore had continuous employment with Plymouth City Council. The Registered Manager confirmed that staff that were new to Frank Cowl House spent a week shadowing experienced staff. The Registered Manager also confirmed that she was provided with good information about agency staff who Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 20 worked at the home, including confirmation that appropriate checks had been completed to ensure that they were fit to work with vulnerable people. Comments from staff in the surveys included: “At Frank Cowl we have a fantastic staff team, who all work as a team to make a happy friendly home.” Also “there is good contact and communication between staff and managers and also good support to both”. Frank Cowl House DS0000030792.V311055.R02.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): 31, 33, 35, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users benefit from a well managed home that is run with their best interest at heart. EVIDENCE: The Registered Managers, Susan Wills, was present in the home throughout the inspection. She has many years experience of working in the care sector and has a relevant qualification- Registered Managers Award. Feedback on the management of the home from staff included: “ The managers are always ready to listen to any problems I have” and “It is one of the better homes, in fact the best to work in. Could not have a better manager. Everyone is friendly and helpful”. One Service User commented in a survey “Sue Wills is a very good manageress. She is very helpful.” Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 22 Ms Wills said that she had spent a number of months in the last year working part time in another Plymouth Home. The Commission had not been advised of this change. The home has a quality assurance system that involves seeking the views of service users who stay at the care home for short stays. The inspectors saw this feedback and it was all very positive. The inspector spoke with the Manager about how this system be further improved. The Manager said that wanted to improve the way they sought the views of service users who were long stay residents. Meetings with Service Users are also held, minutes of the meetings were seen. The Manager said that service users sometimes request her to meet with them if they have issues that they wish to discuss. The Inspector was shown the way that service users money is managed at Frank Cowl House. Each Service User has a safe in their room, where service users need assistance service users staff can access the safe with a key that they must sign for. A record of transactions is kept. The Inspector looked at the receipts for one service user, and it was noted that there was a discrepancy. There appears to be no system for auditing the accounts to identify such discrepancies. Service Users need to be sure that where they need assistance with money that it is properly accounted for. Frank Cowl is well maintained and in good order. The Inspector looked at risk assessments as part of this inspection. There is a fire risk assessment but it did not identify how frequently staff training and drills should be carried out. There was a record of when staff had attended drills, the manager said that staff should attend a drill every month, however the records showed that a few staff had not attended a drill for many months. It appeared that staff who only worked at the weekends or at night rarely attended a drill. The inspector discussed with the manager the need to ensure that the standards set as part of the risk assessment are met. Other risk assessments seen were thorough, but they had not been signed and there were no review dates. One concern raised since the last inspection was the fact that an intruder could gain access to bedrooms on the ground floor, by overriding the window restrictor. Since this concern was identified, additional restrictors have been fitted to the windows. Frank Cowl House DS0000030792.V311055.R02.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 2 2 2 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 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 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 x 2 x x 2 Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes 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. 3. OP3 14 1) The registered person shall 01/04/07 not provide accommodation to a service user at the care home unless, so far as it shall been practicable to do soa) needs of the service user have been assessed by a suitably qualified or suitably trained person: b) the registered person has obtained a copy of the assessment; c) there has been appropriate consultation regarding the assessment with the service user or a representative of the service user; d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the propose of meeting the service user’s needs in respect of his health and welfare. 1) Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare DS0000030792.V311055.R02.S.doc 4. OP7 15 01/04/07 Frank Cowl House Version 5.2 Page 25 a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. 2) The registered person shalla) make the service user’s plan available to the service user; b) keep the service user’s plan under review; c) where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service user’s plan; and d) notify the service user of any such revision. This means that all the residents should have a comprehensive and detailed care plan and individual risk assessments. A record of reviews and consultation should be kept. 3. OP7 , OP9 , OP25 , OP38 12 4) The registered person shall 01/04/07 ensure thata) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks and c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. DS0000030792.V311055.R02.S.doc Version 5.2 Page 26 Frank Cowl House This means that appropriate risk assessments must be carried out in relation to individual service users (including in relation to self medication), that hot water in showers should be regulated as is required by the homes own policy, and that the fire risk assessment should contain specific information about frequency of fire training, and this should be implemented. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office 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. Extracts may not be used or reproduced without the express permission of CSCI Frank Cowl House DS0000030792.V311055.R02.S.doc Version 5.2 Page 28 - 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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