Inspection on 28/02/07 for Freehold Cottage

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 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Freehold Cottage 05/02/09

Freehold Cottage 07/03/06

Freehold Cottage 28/09/05

Freehold Cottage 07/12/04

Freehold Cottage 27/04/04

Freehold Cottage 16/01/04

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

CARE HOME ADULTS 18-65 Freehold Cottage 452 Market Street Shawforth Rochdale Lancashire OL12 8JB Lead Inspector Mrs Marie Dickinson Unannounced Inspection 28th February & 5 March 2007 10:00 th Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Freehold Cottage Address 452 Market Street Shawforth Rochdale Lancashire OL12 8JB 01706 853384 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) kiaran@gmail.com Mr Kiaran Desmond Burke *** Post Vacant *** Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Freehold Cottage is registered to provide accommodation and personal care for six adults with a mental illness. The home is owned and managed by Mr Kiaran Burke. The home is a large detached cottage style building with a garden area to the rear of the house. It is situated on the Market Street a short distance by car /public transport to all local amenities such as shops, post office, library, pubs etc and is situated on a main bus route to neighbouring towns such as Manchester, Rochdale, Bury and Bacup. Resident’s accommodation is in six single bedrooms on the first floor. Ground floor living arrangements include a lounge, dining area, laundry, and kitchen. Information about the service is available from the home for potential residents in a Statement of purpose and Service User Guide. Weekly charges for personal care and accommodation is currently £470. Residents are responsible for purchasing optional extras such as hairdressing, and personal items. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place on the 28th February & 5th March 2007. Information about the service was received at the Commission for the inspection. The inspection involved getting information from staff records, care records and policies and procedures. It also involved talking to residents, staff on duty, and the registered provider/manager, Mr Burke. The inspection included a tour of the premises. Four responses were returned to the Commission from residents who gave their personal view of the services provided. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Younger Adults. What the service does well: Before any services are provided, resident’s needs were assessed. They were consulted about the level and type of care they required. Important information needed to support them in every day living was recorded and used to plan the care they required. This helped to personalise care and inform staff what they should do to achieve this. Professional people helped arrange the care that was needed and staff were trained to provide the right support residents required. Residents were involved in writing their own care plans. This meant personal goals were recognised and staff knew how to help them achieve these safely with the correct support from medical and social care professionals. Discussions with residents and essential information given to them, meant residents could join in all aspects of life in the home. Residents lived their lives in a meaningful way that suited them and helped them with personal development. Activities were personal to them and they had opportunities to make important decisions about their lives. Resident’s views on daily living were positive, and those residents who gave written comments to the Commission said ‘staff listened and acted on what they said.’ The home was managed to avoid any institutional routines, such as set meal times. Staff strictly observed residents right to privacy and dignity. Relatives and other visitors were made very welcome. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 6 Residents living at the home benefited having their own policies and procedures. They received guidance how to keep safe such as fire safety. There were arrangements in place to ensure residents were listened to and any concerns were acted upon. The residents were provided with a clean, comfortable, and well maintained home. They were able to personalise their own rooms according to their own tastes and preferences. Staff in the home were trained, skilled and in sufficient numbers to support the people who use the service. Teamwork was noticeable and staff interviewed showed good insight into the needs of the residents in their care. Residents thought the staff to be ‘very good’ and treated them well. They felt ‘safe.’ Staff were trained in caring for people with mental health problems. They were given other training as part of their professional development. This included important topics relating to Adult Protection such as ‘responding to self injury’ and ‘health and safety’. Seventy five percent of the staff team were qualified to National Vocational Qualification in care level 2 or above The management approach promoted positive relationships between the staff and the residents. The home was very well managed and run in the interests of the residents. The overall atmosphere was open and friendly. Quality assurance processes showed residents had their say in how the home was run and were able to see how well the home achieved the stated aims and objectives set for their benefit. What has improved since the last inspection? What they could do better: To make sure residents medication is administered safely, staff responsible for this task should be assessed as competent, and a formal record made of this training. Adult protection is a very important issue for resident’s wellbeing, therefore formal training in this topic should cover all aspects of protection issues in addition to the extras currently provided such as ‘self harm’. The broken bathroom panel should be replaced and the bathrooms improved in appearance for residents benefit. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 7 Because people living in the home are vulnerable, thorough background checks must be made on new staff before they start work. Staff files should be organised better. This will ensure important information such as supervision notes and training is available for reference. 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. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefited from good assessments, which meant staff, had sufficient information to plan the right care for them. Contracts were given to residents informing them of the terms and conditions of staying at the home. EVIDENCE: There had been no new admissions since the last inspection. There was a protocol followed when new people are being admitted. Policies and procedure show stages to assessment; agency referral, self referral, interview and interview outcome. Records showed health and social care professionals had completed assessments before people had been accepted into the home. The assessments were thorough and detailed, addressing the residents’ personal, social, and healthcare needs Copies of the latest admission assessments completed by health and social care professionals showed sufficient information was recorded to write a plan of care agreed with the resident. Assessments had taken into account the resident’s needs in relation to the type of home environment, staffing levels and current residents living at the home. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 10 Contracts were given to residents. Residents were issued with a handbook that included the terms and conditions of residence and other essential information they need to know about life in the home. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents were involved in writing their own care plans, which meant personal goals were recognised and staff knew how to help them achieve these safely. Discussions with residents and essential information given to them meant residents could join in all aspects of life in the home. EVIDENCE: The standard of residents’ care records was very good. Needs assessed on admission were written into a plan of care detailing how those needs would be met. Residents benefited from being involved in writing their own care plans. They knew what role they must take to make sure goals were achieved; for example, taking responsibility for their own actions in different situations with staff support where needed. Assessment of residents needs was ongoing and care was reviewed regularly. Information recorded included strengths and needs, and showed who had a Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 12 particular responsibility to help reach the desired outcome. In addition to this a contingency plan was written to support staff in taking the right action if the resident was ‘not well’. Residents discussed their hopes and plans for the future, such as living independently. Residents benefited from this level of support from staff. Specialist help required for residents was identified, and details of this support were recorded. Restrictions on residents doing what they liked that may cause them problems was recorded and agreed with them. Residents understood how these agreements helped them. The residents looked after their own money with the help of staff and written records were maintained of all transactions. When residents are admitted to the home they are given their own handbook with essential information such as policies and procedures that affect them. Everything residents needed to know was outlined in the book, and was easy to read. Decision-making was encouraged, and residents were given time to consider individual choices they made that had an impact on their lives. Residents knew about risk management. It was the practice of the home to support responsible risk taking and policies and procedures supported this approach. Risk assessments and management strategies were available. A crisis plan was in place for staff to follow if needed. Written comments sent to the Commission gave a view staff ‘listened and acted on what they say’. During conversation it was evident residents were consulted and able to have their say and join in life in the home. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents were able to make choices about their lifestyle and were supported to develop their life skills. Social, educational, and recreational activities met with the residents’ expectations. Residents were provided with a healthy diet, which they enjoyed. EVIDENCE: The individual plans and care records demonstrated residents had opportunities to maintain and develop practical life skills. Residents were encouraged and supported to participate in the life of the home and carried out domestic tasks linked to their abilities and interests, for example, keeping their bedroom tidy. Resident’s who sent written comments to the Commission said they could do what they wanted at any time of the day. They lived as they wanted to and did Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 14 what they were comfortable with, such as going to clubs, day centres, swimming or just going out for shopping. There was no problem using community facilities. To get out and about residents used public transport or staff took them out in their cars. One resident had her own transport. Preferences for social activities were recorded in care plans, such as, ‘enjoys baking, tapestry work’ and ‘enjoys watching movies.’ Written into residents contract was the option of a seven-day holiday they could choose and plan. Records showed family links and friendships were kept up for residents. Visitors to the home were made welcome and visits could be made in private. The residents had unrestricted access to the home and grounds. The residents were also able to use their room at any time should they wish to spend some time in private. The home was managed in a manner to avoid any institutional routines. For example meal times were flexible, and residents chose when to go to bed at night and get up in the morning. Meals and meal times was a relaxed event. Residents said the food was ‘good’. It was to their liking. They planned their own menus and could ‘help themselves to what they wanted’. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care of residents was based on their individual needs. The principles of respect, dignity, and privacy were put into practice. Assistance with medication was given in accordance with the homes policies and procedures and residents wishes. EVIDENCE: The residents’ individual care plans set out the personal support each resident required. Care plans were detailed and clear what level of support was needed, showing resident and staff role in meeting needs. A record was also maintained of individual likes and dislikes. Residents confirmed personal support was provided in private and staff encouraged residents to maintain and respect each other’s privacy. Residents sign a ‘permission’ statement outlining their wish for staff going in their room. Options were, ‘staff may enter my room if they have not seen me or spoken to me, and are concerned about my welfare’; ‘Staff must knock and give me Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 16 ample warning that they are entering’; or ‘Staff may enter my room at any time if they consider that I am at risk’. The routines were flexible and residents were encouraged to have a bath or shower as frequently as they wished. Some residents managed this themselves however staff support was given to those dependent on some help. Residents personal support was provided in private and observations made during inspection confirmed privacy and dignity were respected. In addition to routine health care, residents were involved with other professional people in their care. This included for example the community psychiatric nurse, psychiatrist, and psychologist. The home operated a monitored dosage system for the administration of medication. This was audited by the supplying pharmacist. An appropriate recording system was in place to record the receipt, administration and disposal of medication. Information sent to the Commission by the provider showed that some staff were trained in medication procedures. Medication administeration is covered in induction. All staff designated to administer medication, should be trained and competent. Care records showed how aging and illness is dealt with sensitively. Residents wishes regarding their care in the event of aging and illness was taken seriously, and their right to live the remaining years of their lives in their home respected. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The complaints procedure was clear which helped residents have confidence to raise any concern they may have. There were policies and procedures, and some training for staff in adult protection issues. This meant residents safety and welfare was promoted. EVIDENCE: Residents who sent written comments to the Commission considered staff treated them well. A copy of the complaints procedure was seen during the inspection. The residents were aware of the procedure and said they would speak to the staff and Mr Burke if they had concern. Residents also considered staff treated them well and listened and acted on what they said. Informal and formal arrangements were in place for dealing with any issue of concern residents may have. This was achieved during daily conversation, and one to one discussion with residents. The issue of residents having valid opportunities to raise concerns was discussed in the homes quality assurance. Staff had access to adult protection literature and procedures, whistle-blowing procedure, confidentiality policy, gifts, wills bequests, professional boundaries for staff and advocacy. Protection issues were covered in induction and staff spoken to were aware of their duty, role and responsibility in protecting Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 18 residents. However formal training in this topic should be made available for staff. To support acceptance of equality and diversity, Freehold Cottage has a statement policy relevant to staff and residents; ‘Freehold is committed to practising and implementing equal opportunities and anti discriminatory practice. Freehold Cottage will not tolerate harassment of service users or staff on any of the following grounds; gender, race, disability, sexuality, nationality, religion, or cultural belief.’ Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents were provided with a warm, comfortable, clean, and safe environment that suited their needs. Resident’s bedrooms were furnished and decorated to their liking. EVIDENCE: Freehold cottage is a detached property situated just off the main Road running through the town of Whitworth. It is located near to a bus route that services towns such as Rossendale Valley, Rochdale and Bacup. The furnishings and fittings were domestic in character and of a good quality throughout. Since the last inspection a new kitchen had been fitted and residents were very pleased with the results. The staff room/office also had new floor covering fitted. Mr Burke said there was a rolling programme of maintenance and ongoing plans to maintain and update the home. This should Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 20 include upgrading bathrooms as a temporary repair had been made to a bath panel. Residents were able to personalise their rooms according to their own tastes and preferences. All the residents spoken to said they liked their rooms, they could lock their doors and have their own privacy. The home was very clean, comfortable, and free from offensive odours, in all areas seen. Those residents who sent written comments to the Commission agreed with this. They felt ‘at home’ and were ‘happy’ with their accommodation. They had access to all parts of the home. Essential maintenance such as fire equipment, gas, and electric had been completed. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home were trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: The current level of staffing was linked to the needs of the residents. Residents who sent written comments to the Commission considered there was always enough staff on duty who responded to their needs. Staff were issued with job descriptions, which set out their roles and responsibilities and was linked to meeting the needs of the residents. Support workers main duties was to ‘encourage clients to feel at home and comfortable at Freehold Cottage.’ A summary of duties and responsibilities included for example; ‘monitor clients health and well being’. Residents were very happy with the staff in the home, and considered all the staff team to be ‘very good’. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 22 Seventy five percent of staff employed was trained to National Vocational Qualification in care level two or above. In addition to this staff have received other training to help them in their career in social care. This included for example ‘self harm’ awareness and management. Staff said they enjoyed their work. They felt supported and were encouraged to attend relevant training. From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and was observed to interact in a positive and pleasant way. Since the last inspection two members of staff had left the home and new staff had been employed. Although no record was made of residents’ involvement in staff recruitment, applicants spent time with them and they could give their opinion of people to Mr Burke. The recruitment and selection procedure did not fully meet with regulatory requirements. Staff had completed an application form and had attended for an interview. Relevant checks had been obtained from the Criminal Records Bureau (CRB). However these were received after employment started. References received however were from credible sources. All new employees undertook an in house induction. Information on the pre inspection questionnaire indicated future training planned included; understanding and responding to self-injury, preparing residents for change, and National Vocational Qualification level three in care. Formal staff meetings were not held on a regular basis. However staff met informally at every change of shift for handover meetings. These meetings gave staff the opportunity to share experiences and develop teamwork. Staff had an annual appraisal of their work performance. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management approach promoted positive relationships between the staff and the residents and the overall atmosphere was open and friendly. The quality assurance processes meant residents were able to see how well the home achieved the stated aims and objectives set for their benefit. EVIDENCE: Since the last inspection, a deputy manager had been appointed to support Mr Burke in the day-to-day running of the home. The management approach was consultative and there were systems in place to consult both staff and residents.Relationships within the home between residents and staff were positive and staff spoke about the residents with Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 24 respect. In turn the residents described the staff as ‘good’ and ‘helpful’. Those residents who completed written comments had confidence to speak to staff over any issue they had. One resident said ‘I have to be honest it’s great here’. Quality assurance and an annual development plan had been carried out. Areas reviewed included for example, needs assessment and support plans, security, health and safety, protection from abuse, fair access, diversity, and inclusion. Confidential records were locked away. Residents held personal copy of all relevant records such as a contract and up to date policies and procedures. The organisation of staff records should improve, as important information was not always readily available for inspection. Staff received health and safety training, which included moving and handling, food hygiene, first aid, and fire safety. Information contained in the preinspection questionnaire and documents seen during the visit indicated essential maintenance such as gas and electrical systems, fire safety had been carried out. Health and safety checks were carried out on the environment regularly, particularly in relation to smoking. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 X 2 3 X Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 26 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. 1 Standard YA34 Regulation Requirement Timescale for action 29/03/07 17, 18, 19 To make sure new staff are schedule suitable to work with vulnerable 2 people, background checks must be done before they start work 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 YA20 YA23 YA27 YA41 Good Practice Recommendations It is recommended staff competency in medication administration be recorded. It is recommended formal training in adult protection be evidenced better. It is recommended the bathroom panel be replaced and the bathrooms upgraded. It is recommended staff files are organised and contain all relevant information required. Freehold Cottage DS0000009524.V326654.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Freehold Cottage DS0000009524.V326654.R01.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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