Inspection on 14/02/07 for Katherine House Rest Home

This inspection was carried out on 14th 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

Katherine House Rest Home 02/02/10

Katherine House Rest Home 17/09/08

Katherine House Rest Home 26/09/07

Katherine House Rest Home 28/02/06

Katherine House Rest Home 24/09/05

Katherine House Rest Home 05/03/05

Katherine House Rest Home 17/08/04

Katherine House Rest Home 18/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE New Cote Rest Home New Cote Rest Home Cote House Lane Westbury On Trym Bristol BS9 3UW Lead Inspector Sandra Gibson Key Unannounced Inspection 14th February 2007 10:45 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 New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Cote Rest Home Address New Cote Rest Home Cote House Lane Westbury On Trym Bristol BS9 3UW 0117 9873540 0117 9873631 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) The Cote Charity Mrs Ann Collins Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: New Cote Rest Home is managed by The Cote Charity and is registered by The Commission for Social Care Inspection to provide personal care to twenty-four residents of mixed gender aged 65 years and over. It is set in secluded grounds a short distance away from Durdham Downs in Bristol. The home is accessible with rooms on one level plus lift to the first floor. The gardens are accessed by way of a sloped ramp. It is situated close to major bus routes and amenities. The City Centre is also a short distance away. The Cote Charity has proposed plans to rebuild New Cote Rest Home and increase the size of the home to accommodate forty residents. The Commission has received no application for Social Care Inspection, therefore the timescale is not known. The range of fees is currently £389.38 and £538.00 / week and extra charges are made for chiropody, hairdressing, toiletries, continence pads, etc. Currently this information is provided verbally prior to admission and then confirmed in writing within a new resident’s contract. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out midweek between the hours of 10.45 am and 7.30pm. Evidence was gathered from: Examining previous correspondence with the home including: Regulation 37 (Death, illness, other events notifications) and Regulation 26 monthly reports compiled by the responsible individual; inspection reports; information from pre-inspection questionnaire, residents surveys (14), relatives comment cards (15), GP / Healthcare Professional surveys (7); talking to/observing residents, talking to the manager, talking to and observing staff, talking to visitors, talking to and case tracking residents; examining records, policies and procedures. What the service does well: What has improved since the last inspection? The management team have continued to make good progress in updating their knowledge and skills since the last inspection. This ensures that residents and staff benefit from good leadership. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 6 The formal system in place to supervise staff has developed further since the last inspection. This ensures that monitoring and support systems provided to staff are much more effective with a result that residents are better protected. The quality assurance system in place has developed further since the last inspection but may benefit from a formal review to ensure that the home is run in the best interests of residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives have the information they need in order to make an informed choice about where to live and admissions into the home are planned with individuals needs having been assessed. However, improvements are needed to the assessment process for those residents who are privately funded to ensure that residents’ individual needs can be full met in this care home. EVIDENCE: Evidence confirmed that Newcote Rest Home has developed a statement of purpose, which sets out the aims, and objectives of the home. There is also a separate residents guide, which provides basic information about the service. The guide is made available to residents in a standard format. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 9 The manager said that residents are provided with a statement of terms and conditions / contract on admission to the home. It gives basic information on what residents can expect to receive for the fee they pay and sets out the terms and conditions of occupancy. This information was not inspected on this occasion. On the whole evidence confirmed that New Cote management team consult the assessment information to see if they can meet the prospective residents needs before they make the decision to accept the application for admission and offer a placement. Evidence confirms that prospective residents funded by Social Services and Health have a needs assessment carried out before they are admitted to the home. For individuals who are self-funding the service is able to demonstrate how they have undertaken an assessment. However, evidence indicated that these assessments were not always satisfactory. From the sample see gaps were found and there was no information that relatives had been fully consulted where appropriate. The manager was able to inform the inspector of those needs, which would not be able to be met at the home, and was able to demonstrate the homes capacity to meet the assessed needs of individuals admitted into the home New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. The care plans and individual risk assessments are not satisfactory . Further development work isy required to ensure that residents’ needs are fully identified and met at all times. The healthcare needs of residents continue to be met with evidence of good multidisciplinary working taking place on a regular basis. The medication administration system is on the whole satisfactory. The system in place now ensures that service users are fully protected and safeguards staff. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 11 EVIDENCE: From the sample of care plans examined it was found that there had been very little improvement in care plans. At the last key inspection conducted in February 2006 it was found that they included more details on how an individual residents needs are going to be met. During this inspection some gaps in this information was found. There was very little evidence of resident or family involvement in compiling the care plans. The practice of obtaining a signature from the resident and/or their representative has not progressed and if not possible the reasons why are not currently being recorded. Evidence confirmed during the inspection that the staff team know individual residents and their needs very well and that the majority of staff treat residents with respect and dignity. However, this information is not always written down. The majority of residents were very positive; “I am very happy living here”. “I am happy land content with everything here. I am very well looked after here”. “Absolutely no complaints about the care and support I receive”. “I am perfectly content with the staff”. The majority of relatives comments were also very positive: “We are and always have been very happy with the high level of care mum receives at New Cote. The manager and staff have always treated mum with respect and kindness.” “My mother continues to receive excellent, personal and thoughtful care at New Cote. She is very lucky.” “A very high level of care provided by a dedicated well motivated staff “ There are long gaps in some of the daily health and personal care records held for individual residents. Written evidence obtained during the inspection indicated that formal reviews of care plans are not taking place. This was confirmed by residents and relatives seen at the time of the inspection. Evidence confirmed that there are risk assessments in place for individual residents. This information is held in the office with residents care plans. Following the last inspection the care plan and risk assessment are now provided to individual residents so they can have a copy available in their rooms. There was no information to confirm that risk assessments are reviewed on a regular basis There was written evidence in place to confirm that General Practitioners, Physicians, District nurses, physiotherapists, occupational therapists and chiropodists continue to be contacted at the appropriate time. Records confirmed that residents were assisted to attend hospital appointments where planned. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 12 Comments received from General practitioners were all very positive. They included, “New cote Rest Home seems to be a caring home and efficiently run” This is a very well organised residential home. In particular the staff know their residents really well, e.g. medical details, social background, likes, dislikes; “The home is very well run.” “Communication is excellent between carers and GP.” Other positive comments were received from health professionals such as “Excellently managed and run home. Residents are happy and cooperative. Staff are always helpful and informed. The atmosphere is of a well run home for the benefit of residents. Communication between residents, staff and myself is good”. However some relatives’ comments were not so positive “Communication between myself and my relative and the staff and GP seem very haphazard. I always have to find an appropriate member of staff and ask for information. Quite important information has come to light when I have asked the right question but I feel more should have bee passed to me via a recognised communication process”. The medication administration system was inspected. New Cote Rest Home continues to use the blister pack dispensing system. The community pharmacist visit on a regular basis to complete an audit and it was noted that the arrangements in place were satisfactory. Information confirmed that staff receive training from the same pharmacist. A sample of computerised medication administration records was checked and they were found to be satisfactory. However, some of the dates on the medication administration records were out of alignment and therefore some dates signed for were not correct. For example staff were signing for the 15th February when actually it was the 14th February. This was consistent in the records seen. The manager explained that the local pharmacist was aware of the situation which was a computer generated error and that they were in the process of installing new computers in the pharmacy within the next week in response to this recurrent problem. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 13 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. Newcote Rest Home enables residents to maintain contact with family, friends and the local community and take part in organised activities within the home. However residents would benefit further from being fully consulted about the choice of activities they would prefer so that the home matches their expectations and preferences. Visitors are made very welcome and meals are well managed and provide daily variation, and good nutrition for people. EVIDENCE: Evidence confirmed that staff are aware of the need to plan the routines and activities of the home in a way that meets the choice and wishes of residents. Evidence confirmed that residents are given the opportunity to take part in a variety of activities both with in the home and the local community. Activities include reminiscence discussions, quizzes, handicraft work, and keep fit. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 14 Trips to local beauty spots are also organised in the Spring and Summer months. Evidence confirmed that a local Church of England vicar visits the home on a regular basis to offer a service for those residents who wish to join in. The manager explained that no current resident has requested support from other faith groups. This information was confirmed in residents meeting minutes. However, evidence from the residents’ questionnaires and relatives’ surveys indicated that not all residents or their representatives were happy with the activities provided. One resident said “ There could be a little more activities” and a relative commented, “Residents need access to more stimulating activities there is only one outing per season”. Evidence confirmed that food and meal times are treated as an occasion and something to be look forward to. Two experienced cooks are responsible for providing nutritional meals that meet the cultural and dietary needs of the service users. The inspector j sat with residents for the communal lunch and observed that care staff are sensitive to the needs of those residents who find it difficult to eat and give them assistance with feeding. They are aware of the importance of feeding at the pace of individual residents, making them comfortable and unhurried. Tables are set attractively with the necessary cutlery and aids to help individual residents. The food is interesting, nutritious, and well balanced. Residents have choice and alternative meals are provided if residents do not like what is on the menu. Hot and cold drinks are provided regularly through out the day and evidence confirmed staff will always make a cup of tea at any time when asked. Comments from residents included, “The food is well cooked and I enjoy it” and “I always like the food provided”. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure must be urgently improved to ensure that residents and their relatives feel confident that their concerns will be listened to and acted up. Arrangements for protecting residents from harm have improved since the last inspection. However systems in place must be further developed to ensure that residents are protected from possible risk or harm. EVIDENCE: The complaints log was examined it was noted that there had been no complaints raised since the last inspection. However following discussions with the manager and talking to residents and their representatives’ evidence confirmed that concerns/allegations had been raised with the management team but there had been a delay in those concerns/allegations being followed through with a result that residents were still distressed and indicated that they did not feel they had been taken seriously. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 16 The majority of residents however, told the inspector that they were comfortable talking to the manager and deputy manager about any concerns. Two residents said: “ I have no complaints, but if I had any concerns I would talk to the manager”. Another resident said, “The staff are very kind here, and the food is good. I have no complaints”. ‘No Secrets in Bristol’ (Local authority Adult Protection procedure) is in place in the home and was noted to be very accessible to all staff. Written evidence confirmed that a programme of adult protection training has now commenced in this home. This information was confirmed by members of the staff seen at the time of the inspection. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe, comfortable, homely environment. EVIDENCE: During the course of the inspection the inspector completed a tour of the communal areas and had the opportunity to view the garden space and several residents, rooms. The gardens of New Cote Rest Home are very attractive and are well maintained. They are also a haven for wild life and residents enjoy watching the birds feed. The inspector was informed that residents may access the gardens located at the front or rear of the house. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 18 The communal areas were found to be clean, smelt fresh and were well maintained. Records confirmed that arrangements for cleaning the home on a regular basis are satisfactory. There is a programme of refurbishment and decoration in place. Records confirmed that repairs are dealt with in a satisfactory manner. Records confirmed that arrangements were in place for residents to have access to the equipment and adaptations they were assessed as needing by health professionals. All residents’ rooms seen during this inspection were found to be safe comfortable and homely and residents confirmed that they could bring items of their own furniture if they chose to. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels at night and during the day are satisfactory so that residents’ needs are met at all times. Improvements in the access arrangements to the staff recruitment system must be made to ensure that residents are fully protected at all times There is evidence of on going development in staff training with the result that residents are being cared for by experienced and knowledgeable staff. EVIDENCE: Residents spoken to confirmed that staff were very helpful and supportive, and that that they were treated with dignity and respect. Surveys received also confirmed this information. One resident said, “ I am very well looked after”. One relative commented, “ New Cote does a good job looking after residents who can be difficult”. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 20 Rotas show ell thought out and creative ways of making sure that the home is staffed efficiently with particular attention given to busy times of the day and changing needs of residents. Agency care staff are currently not used in this home. Staff spoken to during the inspection said that they liked working in the home. Evidence confirmed that management encourages staff members to undertake external qualifications beyond the basic requirements and recognises the benefits of a skilled trained workforce. One staff member has recently completed NVQ3 and another has recently registered From the information seen New Cote ensures that all staff receives relevant training that is targeted and focussed on improving residents lives. The protection of vulnerable adults training has been organised for all members of staff. The staff recruitment system was not inspected as the inspector was unable to access staff personnel files during the inspection as they are now stored in a separate office. The manager explained that this change in arrangements was due to a lack of storage space in New Cote Rest Home. No discussion had taken place with The Commission for Social Care inspection about this arrangement. These records were also not inspected at the last key inspection conducted on 28thy February 2006 as there had been no manager present and the staff on duty had no access to a key. Evidence confirmed that that no member of staff is appointed until a Criminal Records bureau and Protection of vulnerable adults check has been completed prior to staff working in the home. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team have continued to make good progress in updating their knowledge and skills since the last inspection. This ensures that residents and staff benefit from good leadership. The formal system in place to supervise staff has developed further since the last inspection. This ensures that monitoring and support systems provided to staff are much more effective with a result that residents are better protected. The quality assurance system in place has developed further since the last inspection but may benefit from a formal review to ensure that the home is run in the best interests of residents. The systems in place to promote the health and safety and welfare of residents and staff are satisfactory. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager and deputy manager have recently completed NVQ4 in Care leading to The Registered Managers Award. The deputy manager has also completed the manual handling course in training for trainers. Evidence confirmed that they both have completed training courses on an “Introduction to mental health and challenging behaviour” and training for managers on adult protection. Evidence confirmed that the manager is resident focused and leads and supports a strong staff team who have been recruited and trained to a good standard. Formal supervision for all staff members has now been established in this home. This information was confirmed during the inspection. A formal quality assurance system is now in place. Discussion took place how this could be amalgamated with the self-assessment documentation, which is due to be released by The Commission for Social Care Inspection. Evidence confirmed that several representatives from The Cote Charity conduct regular monthly visits. A discussion took place with the manager about the definition of “minor accidents” and what criteria should be used when notify The Commission for Social Care inspection about different incidents affecting the well being of residents. The home has access to professional business and financial advice and has all the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. Evidence confirmed that where the home is responsible for residents’ money that it works to a satisfactory system. Financial records are routinely kept up to date and can be used to track individual residents finances The fire log was examined and it was noted that all periodic tests and checks were up to date. There is now an up to date fire risk assessment in place, which was available for inspection. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 New Cote Rest Home DS0000026512.V329634.R01.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. No. 1. Standard OP3 Regulation 14 Requirement Timescale for action 13/04/07 2 OP7 15 All residents must have a full needs assessment carried out prior to admission to ensure their needs can be met The resident and/or 13/07/07 representative must be consulted when compiling a care plan A signature must be obtained from the resident and/or their representative where possible. If not possible the reasons why should be recorded. This requirement is ongoing from the last two key inspections conducted 24th September 2005 and 28th February 2006. Minor improvement has been seen The registered manager is advised that enforcement action may be taken if improvement does not take place These care plans must be formally reviewed on a regular basis with residents and their representatives where appropriate. New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 25 3 OP8 13(4) 4 OP12 16 2 (m) 5 OP22 16 6 OP29 17 Risk assessments must be reviewed on a regular basis with residents, their representatives and health professionals where appropriate. The programme of activities must be reviewed in consultation with residents to ensure that the activities offered satisfies residents social, cultural, religious and recreational interests and needs and all residents All concerns allegations must be taken seriously and the homes complaints procedure must be followed promptly and effectively. The recruitment records must be held securely on the premises and be made available for inspection 13/04/07 13/07/07 13/04/07 13/05/07 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 New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 New Cote Rest Home DS0000026512.V329634.R01.S.doc Version 5.2 Page 27 - 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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