Inspection on 26/09/07 for Katherine House Rest Home

This inspection was carried out on 26th September 2007.

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

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

Other inspections for this house

Katherine House Rest Home 02/02/10

Katherine House Rest Home 17/09/08

Katherine House Rest Home 14/02/07

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 Jill Cornelius Key Unannounced Inspection 26th September 2007 10:15 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.V345128.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.V345128.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.V345128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2007 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.V345128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector undertook an unannounced inspection with a focus on: • monitoring compliance with core standards which promote the meeting of service users needs with regards to health, welfare and protection. On the day of inspection the home had occupancy of 24 service users with no vacancies. There were a number of requirements/recommendations made during the previous inspection. There are a number of requirements and recommendations arising from this inspection. Sixteen survey returns from service users were received prior to the inspection visit. Eighteen survey returns from relatives, carers and advocates were received prior to the inspection visit. Eight Health Surveys were received. General feedback was given to the manager throughout the inspection process. The majority of the service users and visitors the inspector spoke with were very complimentary of the home, staff and food. What the service does well: 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 satisfactory. The system in place now ensures that service users are fully protected and safeguards staff. Visitors are made very welcome and meals are well managed and provide daily variation, and good nutrition for people. Residents benefit from living in a safe, comfortable, homely environment. Staffing levels at night and during the day are satisfactory so that residents’ needs are met 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. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 6 The systems in place to promote the health and safety and welfare of residents and staff are satisfactory. Our surveys include comments such as ‘there is a high level of personal and team commitment to each resident’, ‘there has never been a time when we as a family have been at all concerned about the care, attention and love of the team for our mother’. What has improved since the last inspection? 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.V345128.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.V345128.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): 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is well managed and service users/representatives are given clear information regarding the service. EVIDENCE: Admissions are taken mostly from local hospitals and the community. Prospective service users are able to visit the home pre admission if they wish. The home has a full admissions procedure in line with legislative requirements; the documentation the inspector viewed during the inspection process evidenced robust pre-admission procedures for private and social services funded people alike. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 9 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. There is evidence in the Care Plan of health care treatment and intervention, and a record of general health care information. There are some gaps in information but staff are able to think in a person centred way and are able to give a verbal update. People living at the home are generally involved in the care planning/ reviewing process. People living at the home are able to access primary and secondary healthcare services. The staff properly manage and administer medication. People living at the home feel they are treated with respect. EVIDENCE: People who use the service responded well to the question from our survey about whether they get enough care and support. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 10 Comments included: ‘They look after me well’, ‘The staff are very good here’ and: ‘they look after us well here’. There was a range of new documentation available in the individual service user care files. Three peoples’ care was tracked and their care plans closely looked at. Care plans were patchy in the level of detail, actions and outcomes recorded. One record indicated that the resident had diabetes in the initial assessment. However there was no detailed care plan for the support required for this in the areas of medical condition, diet or foot care (chiropody). With regards of signs and symptoms to look out for such as, how staff would manage hypo or hyper episodes. This was discussed with the manager and was actioned during the inspection. Another persons record tracked had gained a significant weight over a short time and this was causing mobility problems. An action plan was in place for this. In the three care documents tracked there was evidence for two representatives involvement in the compiling the care plans. The practice of obtaining a signature from the resident and/or their representative has progressed following the last inspection. Discussion took place with the manager to ensure progress in the recording of all care plans. Risk assessments are now being reviewed on a regular basis evidenced in two of the records viewed. However, the other one did not have a signature from the resident or their relatives indicating their involvement. Reasons for this not to be undertaken must be included in the plan of care. A previous requirement about weight monitoring had been met. There was monthly recording and actions relating to this being undertaken. The inspector viewed the medication management this evidenced accurate records for the receipt, storage and disposal of medications. There where no people self medicating. The homes policy for this was viewed and found to be thorough. Therefore safe- guarding people who may use this as a choice for their medication. The last Pharmacy check was undertaken on 07/09/07. All was found to be correct. All residents are registered with a local GP with the home and the inspector was advised there was a good working relationship. There have been recent referrals to the PCT Physiotherapy. The Chiropodist visits residents in the home. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 11 Survey comments from eight health professionals include ‘New Cote is very well organized’, ‘the residents receive very personal care’, ‘New Cote is very well run’, ‘New Cote provides very good, compassionate care to residents’, ‘residents are given time when required to and are dealt with professionally, patiently and discreetly’. During the inspection staff were observed to knock and wait before entering service user bedrooms and toilet doors. Staff and service user interactions were seen to be friendly and supportive. The majority of service user comments indicated staff ‘were courteous’ and ‘respectful’. Another service user informed the inspector that when they used the call bell ‘it was answered promptly’. Survey responses from nine relatives/advocates include: ‘Good help with care and welfare of my loved one’, ‘always keeping in touch with me if there are any problems’, ‘we have had several instances where the care has been exceptional’. Another survey response highlighted that ‘ we would like to be contacted by telephone and not have to wait until a visit to the home for information relating to change in medical condition being told’, ‘communication could be better- information between carers is ad hoc’. General information from the surveys was shared with the manager during the inspection. The response was that she would ensure that all staff are made aware of this and work on making changes if required to the systems of communication. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 12 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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New Cote 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: New Cote has a member of staff who undertakes two afternoon sessions of activities per week. It was noted that on the day of inspection there was no planned activities. However the hairdresser was visiting and undertaking a number of appointments. There is a diary for activities with entries of what has taken place. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 13 On observing the month of September it was noted that there were entries of quizzes, games and reminiscence therapy, one resident said it was “very boring” and that she’ spent her time watching TV in her room’. The TV in the lounge was not on and three residents who were in there were quite happy it was off. Another resident said that he ‘chose not to participate in any of the activities as they weren’t his cup of tea”. Comments from our survey included ‘ I would like to have trips out from the home’. From comments from our survey for relatives, carers and advocates ’offers of activities are not usually taken up by my loved one’, ‘ my loved one wishes to go out more often, possible out to the theatre’, There was information around the home of planned activities to promote them to the resident’s. It was noted that there was a planned Bonfire Supper with Fire Works for November. Three people where looking forward to this. With discussion with the manager she stated that there where plans to increase the hours worked by our activities co ordinator. One visitor said they were ‘able to visit their relatives at any time, and generally do this on a daily basis around the lunchtime period’, another person said ‘their family lived nearby and visited often’. There was evidence in the signing book of various times of the day when visitors came to the home. Menus were looked at together with information about meals from the residents meeting in July 07. Seasonal choices were noted. This gave positive compliments from the residents. There is a choice of one main meal at lunchtime and residents were heard being encouraged to make choices about what alternative they wanted if they decided to change their choice. The menu for the day of inspection was a vegetable lasagne with sauté potatoes. The vegetable choices were in serving bowls on the tables for residents to help themselves. The sweet was a Queens Pudding with cream. This was followed by cheese and biscuits and finished with tea or coffee. Cold drinks were provided with the meal. A couple of residents needed to be assisted with the cutting up of their food and assisted from staff members and this was undertaken sensitively and in an unhurried manner. From our survey comments included: ‘Food is very good tasty meals’ ‘I enjoy my food’ ‘Very good food and there is always seconds on offer’ There were no negative comments made. There was evidence that a number of residents had specific dietary needs, yet nutritional assessments are not undertaken. The home must have processes in place to ensure that nutritional needs are met and that, where necessary, there are systems in place to monitor residents’ likes and dislikes, dietary intake and weight loss. See also standard 7. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 16, 18 There are robust policies in place to manage complaints or allegations of abuse. There are good arrangements in place for staff training and awareness of POVA matters. EVIDENCE: The complaint procedure is prominently displayed in the hallway. The contact information for the area office of Commission for Social Care Inspection is included but requires a change of address and contact telephone number. The manager informed the inspector that this would be undertaken. The manager informed the inspector that all concerns and allegations are taken seriously and the homes complaints procedure is followed promptly and effectively. This has been revised since the last inspection. From our survey people using the service gave a range of answers to the question about making a complaint: ‘I am not aware of any formal procedure and presume that a verbal complaint, if necessary, to a member of staff would have the desired effect’. ‘I know how to moan’ ‘Yes I now how to ‘ One verbal comment whilst at the home included ‘I’ve got nothing to complain about’. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 15 The complaints log was closely looked at. A letter of thanks dated May 07 was seen at the front of the file. This praised staff for the care of a person who was no longer at the home. Two complaints had been received since the last inspection of 06. These had been investigated with outcome letters to the complainant. Training of staff in the area of protection is regularly arranged by the home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe, comfortable, homely environment. 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.V345128.R01.S.doc Version 5.2 Page 17 EVIDENCE: The communal areas were in general found to be clean, and were well maintained. However, on entry to the home in the entrance there was a strong malodour. On discussion with the manger and cleaner this area is continually deep cleaned. This needs to be addressed. Consider the removal of the carpet if it is not eliminated. Residents and visitors to the home highlighted it. Comments from our survey include: ‘Better facilities are needed but we are aware of the issues surrounding the building of a new facility’, ‘Try to eradicate the smell of urine in the passage and entrance area’, ‘There is a strong smell in the entrance and is very of putting’, ‘the general cleanliness in my room is good but when I pass the entrance I can smell something’, ‘When I go to the dinning room there is a smell in the entrance, it is very strong’ ‘Although not brand new it is well cared for in the inside environment’ Records confirmed that arrangements for cleaning the home on a regular basis are satisfactory. Records confirmed that repairs are dealt with in a satisfactory manner. In discussion with the manager it was stated that there where ongoing plans to build a new residential home. As The Cote Charity has applied for planning permission we have not been spending money on improvements, carpets or decoration. 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.V345128.R01.S.doc Version 5.2 Page 18 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: Our survey asked if ‘do the staff listen and act upon what you say’ Out of three service user surveys returned one responded’ most of the time- it depends on who is on duty’, another response said ‘ I think they do’, ‘ yes’. From survey returns from relatives, carers and advocates comments made included that ‘staff give very good care to my loved one’, ‘staff are always helpful’ one negative view was ‘staff seem to be busy and are unable to chat to residents’. Residents spoken to confirmed that staff were very helpful and supportive and that that they were treated with dignity and respect. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 19 Rotas show a well thought out and creative way 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 is currently not used in this home. Staff spoken to during the inspection said that they liked working in the home. Evidence again confirmed that management encourages staff members to undertake external qualifications beyond the basic requirements and recognises the benefits of a skilled trained workforce. Two staff members have 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 living at the home. The addition of a training matrix would enhance the overview of the training needs of staff. The protection of vulnerable adults training has been organised for all members of staff. The staff recruitment system was inspected for three members of staff. These where found to hold all necessary requirements. 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.V345128.R01.S.doc Version 5.2 Page 20 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): 31,32,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team continue 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 continues to be developed 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.V345128.R01.S.doc Version 5.2 Page 21 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 the manager is resident focused and leads and supports a strong staff team who have been recruited and trained to a good standard. From our survey there was one comment’ I do not get told of any changes with my loved one’. Review communication process between home and relatives. This was discussed with the manager. She was happy to review the process of sharing information and would make it an issue on the next staff meeting. Formal supervision for all staff members has now been established in this home. This information was confirmed during the inspection. Internal Quality Assurance system is now in place. Discussion with the manger in relation to the homes qulity reviews took place.She highlighted how open and honest discussions with service users and important others take place, with regular residents meetings taken place, when people who use the service are encouraged to be involved. So that implementation of their requests, to improve the quality of care that they are seeking. Dicussions where possible so that all service users can express their wishes and how they would like them to be met in their assessment of needs. Regular reviews of care plans with service users and important others. 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. An observation was made when visiting the kitchen it was noted that a small domestic size cooker had a broken door hinge. This was highlighted to the chef and the manager to act upon. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 22 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 3 New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement The resident and/or 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. These care plans must be formally reviewed on a regular basis with residents and their representatives where appropriate. 2. 3. OP38 OP26 13 13 Assess the cooker with the broken door hinge and take appropriate actions. Assess the malodour in the entrance and action these findings to provide a hygienic and odour free environment. Nutritional assessment to be undertaken for identified resident. 30/11/07 30/11/07 Timescale for action 30/11/07 4. OP8 12 30/11/07 New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 24 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 OP31 OP1 OP30 Refer to Standard Good Practice Recommendations Review communication process between home and relatives. Update the address and contact telephone number for the local Commission for Social Care Inspection office for all documentation. The manager to undertake the provision of a training matrix. New Cote Rest Home DS0000026512.V345128.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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.V345128.R01.S.doc Version 5.2 Page 26 - 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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