Inspection on 12/07/05 for Keepers Cottage

This inspection was carried out on 12th July 2005.

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

The inspector found 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

Keepers Cottage 24/04/07

Keepers Cottage 16/01/06

Keepers Cottage 22/02/05

Keepers Cottage 22/10/04

Keepers Cottage 11/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Keepers Cottage Falcon Lane, Ledbury, Herefordshire HR8 2JN Lead Inspector Jean Littler Announced 12 July 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Keepers Cottage Address Falcon Lane, Ledbury Herefordshire, HR8 2JN 01531 670772 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Salters Hill Charity Ltd Mr A G Lafford Care Home only. 8 Category(ies) of Learning Disability (8) registration, with number of places Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: In addition to the information on the previous page the registration Condition detailed below has been agreed with the provider. Residents may also have a mental disorder or a physical disability. Date of last inspection 22 February 2005 Brief Description of the Service: Keeper’s Cottage is a rurally based Care Home situated on the outskirts of Ledbury. It is one of a small group of services set up and managed by the Salters Hill Charity. The Home is on two stories and provides accomadation in single bedrooms for eight younger adults, of either sex, with mild to moderate learning disabilities. The home will accept people who are over 18 years on admission and who have an interest working with animals or on the land. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced inspection was carried out on a weekday between 10am and 5pm. The inspector had not previously visited the service so the main focus of the inspection was on meeting the residents and assessing their quality of life. The admission process for the newest resident was also assessed. The inspector met all eight residents, had lunch with five of them and spoke in private with three while they showed her their bedrooms. The manager assisted with the inspection process, and the deputy and a support worker were interviewed in private. Two care plans were sampled and some other records were seen. Feedback questionnaires were distributed prior to the inspection. Two residents returned theirs, both of which were positive. Six relatives of the residents returned theirs, all contained positive information, three were very complimentary and one expressed some dissatisfaction. The inspector followed up these comments over the telephone to discuss the points raised. What the service does well: What has improved since the last inspection? What they could do better: The recommendations that came from the recent Fire Officers inspection need to be further considered and if possible a satisfactory way found to address these. Current First Aid cover falls below the standard so a risk assessment needs to be carried out to ensure the level of cover is sufficient. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 6 Arrangements for infection control through hand washing should be reviewed, as there is a higher than normal risk of infection from the work with animals. The contract issued to residents could be improved if it included clearer information about what things residents will be expected to pay for above their basic fees. Methods of assessing the quality of the service against the standards should be further developed as part of an increased emphasis on self-regulation. 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. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 5. The assessment and admission of a new resident in November 2004 had been managed very well and the existing residents had been appropriately consulted. The contractual arrangements between residents and the Home could be further improved by clarifying any extra costs residents will have to pay above their basic fees. EVIDENCE: There had been a vacancy in the Home last year and four potential residents were referred. Some viewed the Home and met with the residents, who were then asked for their opinions about the suitability of the people. The admission process for the person selected consisted of regular visits and trial overnight stays, which lead to admission on a six months trial basis. This person had been using the day care services offered by the Organisation for the previous two years and therefore was familiar with the Home and the existing residents. Records showed an assessment had been received from the placing authority and the Home had also carried out their own assessment that included staff visiting the person’s current placement. A review meeting had been held to consider the appropriateness of the placement after one and three month intervals. The care plan for a resident who was admitted in 2002 showed the resident had signed a copy of the Terms and Conditions of Residency. The copy issued to the newest resident could not be located. This document should be reviewed as it does not make clear the arrangements for any extra charges to residents e.g. contributions to vehicle costs. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9. Suitable care planning arrangements are in place that fully involve the residents. Residents are encouraged to make informed decisions and take reasonable risks in order to develop their independence. The residents are clearly central to the way the Home is managed and they are consulted regularly about decisions that will affect them. They are fully involved in all aspects of home life. EVIDENCE: All residents can read and staff reported that they encouraged residents to be involved in reading and developing their care plans. A variety of documents in the plans seen had been signed by the residents to show they agreed with them. The care plans contained detailed and helpful information and associated risk assessments for activities e.g. going out alone. Some information e.g. personal profiles were not dated, so it was not clear how current the information was. Residents are encouraged to write a daily diary, and some keep these in their bedrooms. The main care records are in the form of monthly keyworker reports. The manager reported that residents had declined the offer of developing Life Books as they felt they did not need these to have memories of their lives. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 10 Staff and residents reported that residents make a lot of choices and decisions for themselves but are guided when needed. Some attend a self-advocacy group in Ledbury bi-monthly. Others choose not to go as they already feel able to speak up for themselves. A monthly residents meeting is held and this is usually well attended. Keyworkers meet with each resident every six weeks to discuss their needs and wishes so the service can be offered in a Person Centred manner. Formal reviews are being held annually with a less formal meeting held midyear. Families and Social Workers are being invited to these, and care plans and review reports are forwarded to representatives to keep them informed. One resident explained that she was speaking at her review and had agreed with her keyworker who would come and what would be discussed. A digital camera and video have been purchased and these are going to be used to help residents show their friends and family their activities and achievements e.g. progress in horse riding. Residents are being supported to take responsibility for their normal daily living tasks e.g. doing their own washing, preparing food and cleaning their bedrooms. Each resident also has responsibility for a specific management task e.g. weekly fire alarm tests. The staff reported that the resident group mixes well and can make agreements about the Home and communal living. To promote the sense of group living everyone shares a Sunday lunch and some evening restaurant meals are arranged. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16, 17. The Home is achieving its main focus of providing the residents with active and varied lifestyle of their choosing. Independence is being well promoted, but residents are also having to take appropriate responsibility for daily living tasks and maintaining a positive group living atmosphere. Relationships with family, friends and within the community are being encouraged. A healthy and balanced diet is being provided and mealtimes are sociable occasions. EVIDENCE: The residents were all busy during the inspection. Some were doing household tasks like putting the bins out for collection, before helping unload the ten new hens and settling them into their fox proof run. Others were out at their regular activities including horse riding, and the Organisations’ Land and Livestock course. All residents have pictorial timetables in their bedrooms and these showed a wide variety of activities are being accessed e.g. gardening, woodwork, gym, college, church, sewing and art. One resident works two mornings a week at a local rescue kennels and cattery. Other work placements are currently being Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 12 set up. A volunteer holds weekly numeracy and literacy classes for those who are interested. Social activities are offered e.g. the Ross Leisure Link activity and social evenings, but residents decide themselves what they want to attend. Each member of staff plans a day trip during the college holidays. This summer these included the Safari Park and the seaside. Residents choose if they wish to goon these trips, or not. Residents also choose two friends to join them for an evening out on their birthdays. One resident had made his plan as his birthday was the following day. Residents chose which holiday they want to go on and who to go with. One resident had chosen to spend a week with her mother and then to go on a variety of day trips including canoeing. A payphone is provided, which is situated under the stairs but it can also be plugged into each bedroom for increased privacy. Relationships with friends and family are being supported e.g. one resident’s mother is unwell so staff have been driving her to the family Home so her visits are not affected. None of the residents have yet made friends with anyone who is not linked with the service in some way. This should be discussed with them to see if they would like more opportunities to make new friends in the local community, e.g. through regularly attending a hobby related club. A healthy diet and way of life is being promoted. A programme called ‘FoodFun-and-Fitness’ is currently being worked through which includes weekly menu planning. The aim is to assist the group in becoming better informed and more aware of their body image and preventative health needs. A record of the meals provided is kept. One resident said she was trying to loose weight and the staff are supporting her with this aim. The residents spoken with said they liked the food, which is either home produced or purchased locally. Residents are all able to choose what meals are prepared and can help themselves to a menu alternative. The inspector joined everyone at home for the lunchtime meal, which was eaten in a relaxed and sociable atmosphere. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19. Suitable health care arrangements are in place and the residents have been consulted about their needs. EVIDENCE: Staff support residents with their personal care mainly through prompting them. The details of the support they need is included in the care plans. Following a relatives concern about the treatment of a skin condition daily monitoring is carried out by staff. The residents spoken with confirmed that the staff are helpful and patient when assisting them. Health plans that are in a format suitable for the residents have been completed. The residents have been fully involved in completing these and have signed them. The GP and District Nurse had also provided some assistance. Preventative health checks are taking place e.g. one resident had attended a Wellmans health check the previous day. Where residents have a specific health condition specialists oversee their treatment. The medication system was not inspected, however one resident holds his own medication and has lockable storage for this purpose. The manager agreed to review the arrangement for another resident who is not holding her own medication but seems to have the potential for this. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23. There are systems in place to promote and manage any complaints. The Organisation responds positively when concerns are raised. Suitable arrangements are in place to help protect residents from the risk of abuse. EVIDENCE: A Whistle Blowing, Abuse and Complaints procedure are in place and staff have received training in these areas. A worker spoken with felt she and all other staff would raise any concerns promptly and that abuse of any type would not be permitted in the Home. All residents have the capacity to make complaints or alert staff if they were unhappy or being poorly treated by someone. The residents spoken with indicated they found the manager approachable. A telephone call with a resident’s relatives provided information that they had raised some concerns in the last year and a half. Details of two specifically were given, the treatment of a skin condition in 4/04, and their son being left at a sports centre to meet a group of people, who did not turn up in 11/05. The manager and directors had reportedly been very responsive and had held meetings to address the concerns. The family were pleased with the attitude taken to the complaints and hoped that similar circumstances would be prevented by better planning and communication within the Home. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25,26,30. The Home is generally well suited to its purpose and provides a pleasant home for the residents. Fire safety issues need to be worked through over the coming months. The house is clean and has been well maintained and ongoing improvements are being made. EVIDENCE: The Home is being well maintained and is clean and homely. It is well suited to its purpose with the exception of two issues outlined below. There are plans to further improve the facilities by adding a shower to one of the bathrooms. One bedroom is undersized. A Fire Safety Officer visited the Home in May 05 and has made three recommendations. Two of these are proving difficult to implement due to the design of the building. Further negotiation with the Fire Authority is needed so a way forward can be agreed, or the providers need to be very clear in their Fire Risk assessment why they have not followed the Fire Officers advice. One bedroom is under sized, however the recommendation made at the last inspection, to explore the possibilities of increasing the usable space to improve the room were not discussed on this occasion. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 16 Bedrooms have been nicely personalised e.g. favourite football teams, family photos, swimming medals, and residents had their own towels and bedding. One resident said she did not like the creases in her wallpaper. Her room has not been redecorated since she moved in four years previously. The manager agreed to arrange for her keyworker to discuss this with her and make some plans. Anyone moving into the Home should have the opportunity to decorate their room in a design of their choosing. The residents help to keep the Home clean by sharing cleaning tasks. Food is being stored appropriately in the fridge. Suitable laundry facilities are provided and residents do their own washing separately. Everyone washed their hands in separate facilities after their morning work tasks before making their own sandwiches for lunch. Although pump soap is provided hand towels are used in communal areas, as these are considered more homely. Although they are being laundered daily sharing towels does increase the risk of cross infection and their use should be reviewed, particularly as animals are kept. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36. The residents are being appropriately supported by a well trained staff team and sufficient staffing levels are being maintained. Staff are clear about their roles and effective professional development and supervision arrangements are in place. EVIDENCE: The two members of staff spoken with were clear about their role and that of the other staff in the Home. They were both obviously committed to the residents and the aim to promote choice and independence. The residents and staff engaged positively with each other and the residents spoken with said they liked all the staff. The work with residents showed appropriate staffing levels are being maintained. The rotas confirmed that at least two staff worked during the day and one slept in at night. No agency staff are being used. New staff are due to start the following week to fill two current vacancies. Volunteer drivers are engaged to support the residents to access their day and community activities. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 18 Recruitment records were not seen on this occasion as no new staff had started since the last inspection. New staff usually start when a POVA First check has been received, prior to the full CRB being returned. In line with the Department of Health Guidance for POVA this process should only be used in exceptional circumstances. The manager is advised to record on the staff files what the staffing situation is at the time the decision to use POVA First is made, to evidence that this system is being used appropriately. Staff spoken with reported that training is promoted and good arrangements are in place for core safety training and refreshers. Courses are provided across the Organisation at two monthly intervals. Additional more specialised training is also provided, but places sometimes become available at short notice, which can lead to difficulties in staff being freed up to attend. Newer staff are being assisted to work through the LDAF induction and foundation units. Some staff have already achieved NVQ awards, others are currently being supported to achieve these and some with one award are now working towards a higher level. An external training provider is used, however the manager and deputy are NVQ assessors and they also support candidates. Staff are being provided with regular supervision sessions with the deputy and the manager has recently been holding annual appraisals. Staff meetings are held each month and staff spoken with said these are open and constructive. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40,42. The Home is being well run by a competent and approachable management team. Appropriate records are being maintained and effective health and safety management systems are in place. Systems are in place to gather feedback from stakeholders and assess the quality of the service in some areas. These systems should be further developed to increase the selfregulation process. EVIDENCE: The manager is suitable qualified and experienced for the position. He takes time to find out what residents are doing outside the Home by visiting them at their college and other daytime activities. The deputy, an administrator, and other managers in the organisation who work collaboratively on certain issues and developments provide additional management support. Some management duties including Health and Safety have been delegated to the deputy who has two administration days a week. He represents the Home at the Organisations regular Property Management meetings. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 20 The staff and residents reported that the manager and deputy are both approachable and helpful. Systems are in place for gathering feedback from residents, staff and other stakeholders. To inform people involved with the Organisation a periodic newsletter is circulated, which service users from across the Charity contribute to. The quality assurance system currently includes a variety of questionnaires that are issued to residents and other stakeholders across the Organisation, which are then collated centrally. A full day is then held where those involved review this information and begin to formulate the business plan for the coming year. An AGM is held and a separate relatives meeting are also held annually. Residents’ in-house meetings are held regularly and named keyworkers have the role of liaising closely with specific residents on an ongoing basis to ensure they are satisfied with the service. A provider’s representative also visits monthly to assess the service and provide reports to the Commission and the Charity directors. A Quality Policy is being developed currently. This should clearly detail how all standards will be measured so the requirements of regulation 24 and standard 39 will be met on an ongoing basis. All residents have their own current and saving accounts and their fee contributions are paid by standing order to the Organisation. The manager is appointee for five residents and for three others this responsibility is held by a relative. An application to allow some residents to be solely responsible for their own money has been refused after an officer from this Government department came to the Home to assess the residents’ capability levels. A sample of records for residents’ monies showed money is being accounted for and residents are signing when they take some of their money out. The deputy reported that assessments are completed for any significant risks and he confirmed these are reviewed regularly. A regime of regular checks are taking place to control the risk of Legionella including running all taps weekly and annual checks on the water storage tanks. Risk assessments form part of each residents’ care plan. The facilitator of the woodwork sessions completes specific risk assessments for this activity. Core Health and safety training is being provided for staff and some residents also have attended courses e.g. Food Hygiene. Staff are usually only trained in basic first aid. If the providers want to provide a level of First Aid cover which is below the National Minimum Standard then this must be on the basis of a risk assessment. Records showed fire safety checks are being carried out and staff reported they receive fire training and practice evacuation drills. As detailed above some Fire Safety premises issues are still under consideration. Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 4 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 4 4 4 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 x x x 2 Standard No 11 12 13 14 15 16 17 4 4 4 4 4 4 4 Standard No 31 32 33 34 35 36 Score 3 3 3 4 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Keepers Cottage Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 4 3 x 3 2 x E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42. Regulation 13,18. Requirement A risk assessment regarding the need to provide a Qualified First Aider at all times must be completed and forwarded to the Commission. Any additional staff training identified from the risk assessment, if any, must be completed by the end of March 2006. Timescale for action 30/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA5 YA19, 20. YA30 YA39 Good Practice Recommendations Review the Terms and Conditions document and ensure it is clear about any extra charges that will be made to residents e.g. vehicle costs. Ensure residents are enabled to manage their own medication whenever possible. Hand drying arrangements should be reviewed inline with good infection control practices. Further develop the quality assurance system to measure the outcomes of the service against the Nation Minimum Standards. The periodic progress reports to stakeholders and the Commission should detail a cycle of improvements. E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 23 Keepers Cottage 5. YA41 6. 7. YA25 YA26 The Care Manager is advised to remind staff to date all entries in care records to ensure their current relevance and overall value. (Brought forward as this has not been fully actioned). Explore the future possibilities of increasing the usable space in the smallest bedroom. (Brought forward, as not discussed at this inspection). Offer any new resident the oportunity to decorate their bedroom in a manner of their choosing. Have an agreement about how regularly the Organisation will pay for residents bedrooms to be redecorated. Offer them the chance to redecorate more frequently than that if they want to pay for this themselves. Further develop quality monitoring systems so the service is regularly reviewed against all the National Minimum Standards. The method of reporting to stakeholders and to the Commission shows an ongoing cycle of improvements. 8. YA39 Keepers Cottage E52 - E02 S24718 Keepers Cottage V233102 120705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Hereford CSCI Area Office 178 Widemarsh Street, Hereford, HR4 9HN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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