Inspection on 21/07/08 for Pool Cottage Care Home

This inspection was carried out on 21st July 2008.

CSCI found this care home to be providing an Poor service.

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

Pool Cottage Care Home 06/01/09

Pool Cottage Care Home 30/05/07

Pool Cottage Care Home 30/06/06

Pool Cottage Care Home 23/01/06

Pool Cottage Care Home 26/09/05

Pool Cottage Care Home 09/03/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Pool Cottage Care Home Pool Road Melbourne Derbyshire DE73 8AA Lead Inspector Claire Williams Unannounced Inspection 21st July 2008 09:30 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 Pool Cottage Care Home DS0000061459.V368765.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. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pool Cottage Care Home Address Pool Road Melbourne Derbyshire DE73 8AA 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) 01332 863715 01332 863715 poolcottage@clara.co.uk Mutebi Blessious Kalemeera Jennifer Susan Williams Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2007 Brief Description of the Service: Pool Cottage is a detached property, which has been adapted and extended to provide personal care for up for up to 17 persons aged 65 years and over, and day care for up to 3 persons. The home overlooks Melbourne lake and is close to the town centre, local shops and a bus route. The home has 11 single and 3 double bedrooms located on the ground and first floor, 7 bedrooms have ensuite facilities. Access to the first floor is by stairs and a stair lift. There are 2 lounges, a conservatory and a dining room on the ground floor. The Home has a garden. Information about the service is provided through the Statement of Purpose and Service User Guide, both of which were made available to individuals. Information included on the pre-inspection questionnaire received on 04/05/07 stated that the fees for the home were £367.00 to £402.00 per week, and that this information was also included on the contracts and terms and conditions. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is Zero Stars. This means the people who use the service experience Poor quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 7 hours. In order to prepare for this visit we looked at all the information that we have received. This included: • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of two people representing a cross section of the care needs of individuals within the home. Discussions were held with those individuals as able, together with a number of others about the care and services the home provides. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. What the service does well: People spoken with said that they found the move into the home a supportive experience, and were pleased that they were able to bring some of their personal possessions for their bedrooms. Most of the people had previously visited the home or had a period of respite, which they said, “helped them make the decision about moving in”. People spoke positively about the support and care they received from the staff team who they described as “very attentive”, “they work very hard”, “they are friendly and caring”. People said their needs were met to a good standard and with “dignity and respect at all times”. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 6 Feedback provided in the surveys also supported that people were supported in accordance with their needs, and comments made included “the staff do a good job, they give us fun, and are very helpful”; People were happy with the environment, which they said was homely, and all of those spoken with liked their bedrooms. There are systems in place to enable residents to provide feedback about the home and make suggestions for improvements. Visitors spoken to said the staff made them feel welcome and keep them informed of their relatives well being. They said that generally there were satisfactory staffing levels but at times there was staff shortages. The staff team reported that they work well together and have access to training opportunities to enable them to have the skills and knowledge to fulfil their roles. What has improved since the last inspection? What they could do better: The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. The information obtained and recorded about each individual would benefit from being in more detail so that person centred care can be delivered and underpinned by written records. The recruitment practices must protect people, and staff must only commence employment after all required checks and information has been obtained. The staff team must have access to mandatory training so that they have the skills and knowledge to fulfil their role and support people safely. Staff would Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 7 benefit from having training about the mental capacity act so that they are aware of the new legal rights people who live in this service have. This will enable the staff team to promote these rights. There are concerns about the financial viability of the service and the impact this is now having on the people who live in this service. 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. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 8 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 Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 9 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): National Minimum Standards 1, 3 and 5 (stranded 6 not applicable) Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People are assessed and have access to information to enable them, to make an informed decision about moving into this service. EVIDENCE: In the self-assessment that we received they said they always ensure that people are assessed before they are admitted to the service. People are encouraged to undertake trial visits in order to familiarise themselves with the home and the staff. It was reported that the Statement of purpose and Service Users Guide have been updated within the last 12 months, and that all people have been provided with a copy. The fees and what they cover are not included in the Statement of purpose but this information will now be added as an attachment. Individuals spoken with said they have access to information about the service. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 10 People spoken with also confirmed they had been assessed before they moved into the home, and this was supported by the assessments in the 2 files that we examined. Individuals spoke of varying reasons as to why they chose this home, and these included: “I have lived in this area all my life and did not want to move elsewhere”, “I came to visit and stayed for respite, so I got used to it here and decided to live here permanently”. People spoken to said they found the staff to be “supportive, and kind”, during the admission process. The home does not provide intermediate care and there were no people accommodated at the time of the site visit with diverse cultural or religious needs. It would be beneficial however for all documentation to be reviewed considering the six areas of diversity, so that is it inclusive to all people. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 11 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): National Minimum Standards 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive the care they need and this is provided in a way that upholds their dignity. EVIDENCE: In the self-assessment that we received they said: they complete care plans with individuals and review these monthly or when required. All required risk assessments are completed with individuals and these are also kept under regular review. They said that only seniors administer medication and they have received training in this area. They said that people are supported with personal care in a respectful way and to maintain their dignity and privacy. All care files contained an assessment of need and care plan. Although these contained sufficient information to inform the delivery of care the plans were not completely person centred and holistic. They focused mainly on what support individuals required and limited information was available about what a person is able to do. There was information about the person’s background and about individual’s likes, dislikes, routines and preferences, but these areas Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 12 could be expanded upon in order to assist the staff to deliver individualised care. There was evidence that the plan of care was reviewed on a monthly basis with the individual, which is good practice. This ensures that the plan reflects individual’s current needs. Records were completed of peoples general well being, and these were to a good standard. Each file contained risk assessments and risk management plans to help staff support people in a way that will minimise any risks, and to monitor any key health needs. People who we spoke with said they have access to healthcare professionals, when they need them, and the records supported this. In discussion with the staff team it was clear they had a good understanding of each persons needs. A key worker system is in operation and staff members said they enjoyed this role as it meant working closely with individuals. People told us they receive their medication in accordance with their wishes. There were records to support that medication was stored and administered as prescribed. It was reported that all staff that administer medication have undertaken some form of training in this area. A formal written assessment of staff medication practices has not yet been completed. This will ensure that staff are supported and competent in this area. Due to a change in the law the storing of controlled drugs must now be in accordance with the new legal specifications and this service needs to ensure they meet these requirements. All people spoken with said that support is provided in a “safe, respectful and dignified manner”; People said the staff; “work very hard to help everyone”, “are kind and considerate”, “friendly and caring”, and “provide excellent care.” Pool Cottage Care Home DS0000061459.V368765.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): National Minimum Standards 12 to 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to lead a lifestyle of their choosing, which ensures the services matches their expectations and preferences. EVIDENCE: In the self-assessment that we received they said; they respect individuals routines, and daily choices. They encourage and welcome visitors, and have good links with the local community groups. They provide daily activities and aim to take people on a trip out at least monthly. All care files that were seen contained some information concerning people’s social needs and likes/dislikes; some of this information was part of the care plan documentation. This ensures that staff have access to information about what individuals like to do enabling them to meet peoples social needs. An ‘residents board’ is available for people to access information about forthcoming activities or events, and a colourful newsletter is produced each month detailing this information. The newsletter for July stated that that following activities have been planned; a church service, trip out to ‘well Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 14 dressings’, BBQ with the local army cadets, summer fete, and the Melbourne festival, which the service is participating in. People also have access to daily activities such as bingo and music and nail care which were the activities on the day of our visit. People said they have lots to do and were satisfied with the activities available. People said their visitors are “always welcomed into the home”, and they spoke of the good links the home had with the community. Some individuals attend the community events. We were informed that the tea-mornings continue to be popular with the local people and the individuals in the home. People told us that their daily routine was flexible; they could choose what time they rose and went to bed. People who wanted to stay in their bedrooms were able to do so. People’s preferred rising/retiring times were also stated in their care documentation, along with their preferred form of address, this helped to ensure care was more person-centred. People told us the food was ‘good’, and individuals are encouraged to serve themselves from the dishes, which are located on the table. This is good practice as it encourages individuals to be independent, and to choose the amount of food they would like to eat. People have choices at each mealtime and dietary requirements are met as observed during the lunchtime. Individuals that required support received this in a dignified and respectful manner. Pool Cottage Care Home DS0000061459.V368765.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): National Minimum Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are kept safe through effective complaints and safeguarding policy and procedures EVIDENCE: In the self-assessment that we received they said; they have a clear complaints procedure, which is displayed, and that all complaints are dealt with promptly. Staff have received training in safeguarding adults and are aware of the procedures for reporting such incidents. There have been no complaints about the service raised with us since the last inspection. No complaints had been received by the service either. A record is in place for the purpose of recording complaints and the procedure is displayed as stated in the self-assessment. People spoken to, told us they had no complaints and knew whom to approach should they need to raise any issues. People told us they were confident the Registered manager would sort any issues out. Staff told us that they had attended safeguarding training, and during discussions they demonstrated their awareness of what action to take in the event of witnessing a potentially abusive situation. The staffing matrix indicated that 2 members of staff, have not had training in this area, but one member of staff is currently completing an National Vocational Qualification Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 16 and will undertake this training as part of this award. Therefore only one member of staff is required to access training to ensure they are aware of the principles and procedure to safeguard people. We have not been advised of any safeguarding issues since the last inspection report. The required safeguarding procedures are in place to provide guidance on the procedures to follow as stated in the self-assessment. The manager had received information about the Mental Capacity Act and intends to try and access training in this area. It was advised that some forms should be obtained so staff could record decisions people made, which are in line with the requirements of the Mental Capacity Act. Pool Cottage Care Home DS0000061459.V368765.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): National Minimum Standards 19, 20, 21, 23, and 26. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Although people were satisfied with their surroundings which was homely, safe and met their needs, lack of redecoration indicates little way of investment of the home. EVIDENCE: In the self-assessment that we received they said: we provide a safe, homely partly listed building for people to enjoy. The pool surrounds it and there is plenty of seating areas outside. They said the home is clean and hygienic and all equipment is regularly maintained. They said they would like to upgrade the furnishings and redecorate certain areas, but due to the financial constraints this is not possible. They have identified that new door closures have been fitted in order to ensure they comply with the fire regulations. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 18 People who were spoken to said they liked the communal areas and in particular their bedrooms which they had personalised with their belongings. People said they made “good use” of garden and the “stunning surroundings”. People said they have access to various aids and equipment in order to assist them in their mobility and to get around the home. During a tour of the building it was identified that some areas would benefit from upgrading and redecoration. This was highlighted in the previous report but no renewal work has been undertaken other than in response to health and safety requirements. As stated in the last report a renewal programme is in place but there continues to be limited progress made in achieving the targets due to insufficient investment from the provider. We were informed that the kitchen still needs new crockery and continues to have items donated to ensure there is enough for the people to use. Several carpets were stained such as the lounge carpet, but we were informed that there are no resources this year in order to have these cleaned. Although renewal is required in areas, people did state they were satisfied with the environment and said it was homely. Observations supported that the environment was safe for people to use. Pool Cottage Care Home DS0000061459.V368765.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): National Minimum Standards 27 to 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although people are cared for by sufficient numbers of well-trained staff the recruitment practices do not ensure people are safeguarded. EVIDENCE: In the self-assessment that we received they said they have a good staff mix, and are able to provide additional staffing during peak times. They said staff are recruited in accordance with the procedure and to ensure the welfare of individuals in the home. They said they provide staff with training, supervision and appraisals. The number of staff on duty on the day of the inspection was consistent with the numbers identified on the staffing rota. The staffing levels were in accordance with the needs of the individuals currently living in this service. People told us that there are always sufficient staff members on duty, and that their needs “are always met”. Staff members spoken with also felt that they were able to provide a good standard of care and complete all tasks. People made positive comments about the staff team, which included; “they are marvellous and do a grand job”, Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 20 “They work very hard and are very kind and helpful”, “ they are excellent and brighten my day”. Information provided at the time of our visit stated that 12 out of the 23 care staff have achieved an national Vocational Qualifications in care subjects at level 2 or above, and 3 members of staff are currently undertaking this training. The staff team is a stable group and when we spoke to individuals they said, “staff worked well as a team”. They are motivated and committed to their work, and one comment made included: “we enjoy working with the people who, live here”. The files for three newly employed staff were examined. All of the required information was available but it was identified that staff had commenced duties before their police check had been returned, and a check to ensure they were not on the Vulnerable Adults register (Povafirst) had not been undertaken. This has the potential to place people in this service at significant risk. It was reported that the staff were supervised at all times until the return of their police check. It was also reported that a Povafirst check was not undertaken due to financial constraints. The staff files and the training matrix demonstrated that staff have access to training, and there were certificates to support the training received in the files. However it was reported that recent mandatory training had been cancelled due to the ongoing financial constraints on the service. Some staff are currently undertaking infection control training through the distant learning route. An induction pack had been obtained from skills for care and it was reported that all new staff members are currently completing these. This will ensure they have the skills and knowledge to fulfil their role and provide a good standard of care. Pool Cottage Care Home DS0000061459.V368765.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): National Minimum Standards 31, 33, 34. 35, and 38 Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The service is not being managed in the best interests of the people due to the ongoing financial constraints. EVIDENCE: In the self-assessment that we received they said; the manager is experienced in her role and undertakes the required training. They said that the financial constraints by the provider over the last 3 years have made their jobs very difficult. They said they have good links with people’s families, friends, and healthcare professionals, and monitor all aspects of health and safety. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 22 The staff team and people spoken to made positive comments about the manager who they said; was experienced, supportive, caring, and approachable. People said they are consulted about aspects of the service through the provision of meetings, questionnaires and informal discussions. It was reported that quality assurance surveys has been distributed to various to people who live in service and their families, and that a report will be completed of the outcome. People said they are able manage their finances if they wish, but many said they have given their consent for the management team to do this. People said they were happy with the systems in place, and when checked these were satisfactory. As mentioned some mandatory training had been cancelled and this included moving and handling training, which 2 staff members require. The training matrix indicated that 6 staff members have not completed food hygiene. It was reported that all other aspects of health and safety were monitored and risk assessments completed as required. Staff said they felt supported by the manager and records in place indicated that supervision is undertaken on a formal basis, and through the observing of staff practices. This ensures staff work in accordance with good practices and safely. There was evidence of visits that had been undertaken by the provider, but these had not been undertaken consistently on a monthly basis. The visits were also undertaken in the evening, which means that the provider does not have the opportunity to see the management team. It was reported that the manager has very little contact with the provider in order to discuss the running of the service and therefore has very little formal support from him to manage the service and discuss issues. As mentioned within the report the ongoing financial constraints, are having an impact on the delivery of the service. These include; the recruitment practices, the ability to renew certain areas of the building, and purchase new crockery, and the availability of booking refresher mandatory training. It was also reported that certain suppliers will no longer accept cheques as payment from this service due to these ‘bouncing’. Therefore cash payments are now being paid in order to purchase the food supplies and for minor maintenance repairs. The Commission for Social Care Inspection are in contact with the provider to discuss these issues and the financial viability of the service. Pool Cottage Care Home DS0000061459.V368765.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 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 1 3 X X 2 Pool Cottage Care Home DS0000061459.V368765.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 OP7 Regulation 15 (1) Requirement Timescale for action 01/11/08 2. OP9 13 (2) 3. OP19 23 (2) (b) 4. OP29 19 (1) (b) Person centred plans must be developed for all people to reflect how the person would like their support to be provided. They must also include reference to the individual’s ability to make decisions under the requirements of the mental capacity Act. The current storage for 01/10/08 controlled drugs must be checked to ensure it complies with the royal pharmaceutical requirements. This is to ensure medication is stored in accordance with the law. The renewal and redecoration 01/11/08 plan must have clear timescales and sufficient investment in order achieve the targets identified and achieve the upgrade of several areas of the home. The timescale for this requirement was 01/09/07 and this has not been met. Staff must not start employment 01/08/08 until all of the required checks and information has been obtained to ensure they are DS0000061459.V368765.R01.S.doc Version 5.2 Pool Cottage Care Home Page 25 5. OP30 18 (c) (i) 6. OP31 26 7. OP34 25 (1)(2) 8. OP38 18 (c) (i) suitable to work with vulnerable people, and to ensure people are safeguarded. All of the staff must attend mental capacity training to ensure they work in accordance with this new legislation and promote individuals rights to make decisions about their lives. The provider must undertake visits and reports on a monthly basis and these must be available in the service for examination. This is to ensure the provider is monitoring standards in the service. The registered provider must carry on the care home in such a manner as is likely to ensure that the care home will be financially viable for the purpose for achieving the aims of adjectives set out in the statement of purpose. All staff must access the required mandatory training to ensure they have the skills to fulfil their roles and work safely so that people are not at risk 01/09/08 31/08/08 01/11/08 01/11/08 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. Refer to Standard OP2 Good Practice Recommendations The admission records should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. These areas should be completed for each resident. All staff who administer medications should be assessed to ensure they are competent in this task. DS0000061459.V368765.R01.S.doc Version 5.2 Page 26 2. OP9 Pool Cottage Care Home 3. OP15 The kitchen should purchase new crockery to be able to serve meals and drinks to people. Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Pool Cottage Care Home DS0000061459.V368765.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!