Inspection on 30/05/07 for Pool Cottage Care Home

This inspection was carried out on 30th May 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

Pool Cottage Care Home 06/01/09

Pool Cottage Care Home 21/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pool Cottage Care Home Pool Road Melbourne Derbyshire DE73 8AA Lead Inspector 0Claire Williams Key Unannounced Inspection 30th May 2007 09:00 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.V338868.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.V338868.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.V338868.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2006 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 residents. Information included on the pre-inspection questionnaire received on 04/05/07 stated that the fees for the home were £365.54 to £388.85 per week, and that this information was also included on the contracts and terms and conditions. Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over a period of a day (7 hours). Additionally, time was spent in preparation for the visit, looking at previous inspection reports and other relevant documents and preparing a structured plan for the inspection. Surveys were sent to the people living in the home in order to gain feedback about the quality of the service, and 11 surveys were returned. 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. Where possible, we include evidence from other sources, notably District Nurses and Social Workers. We also use information gathered throughout the year, to support our judgements. This may include notifications from the provider, complaints or concerns and the pre-inspection questionnaire, which the Registered manager completed prior to a visit to this service. The primary method of inspection used during the visit to this service was ‘case tracking’. This involved selecting three people and tracking the care they receive through the examination of their care plans and associated care records, inspection of their private and communal accommodation, and discussions with them or their representatives and the staff team. During this visit time was spent undertaking a brief tour of the service, looking at records and speaking to the people and staff about their experience of the home. Lunch was spent with the residents and medication was also examined. The Registered manager assisted the inspector with the inspection and all of the key standards were inspected on this occasion. Following discussions with the people who live at this service it was agreed that for the purpose of this report they would be referred to as ‘residents’. What the service does well: Residents have the opportunity to undertake visits to the home and have an assessment completed in order to assess if the home can meet their needs. Feedback from residents and their relatives indicated their satisfaction with the running of the home and the care and support they receive as many positive comments were made about the staff team and the management of the home. Some comments included: “The manager is really caring and approachable and manages this home well ” Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 6 “the staff are excellent and are always around”. “The food is excellent and choices are always offered”. “The routines are flexible and we have plenty to do if we want to”. “The home has a lovely atmosphere and some lovely views I am happy here”. Discussions with the staff team confirmed their commitment and knowledge of the resident’s specific needs and preferences and how these are to be met. Good working relationships were observed between the residents and the staff and management. Managers and staff are competent in their roles and knowledgeable about health and safety requirements and legislation and their practice routinely protects and promotes the safety of people. The manager provides good leadership to the staff team and ensures that they are appropriately resourced, trained and supported. Systems are in place in order to obtain feedback from the residents and their representatives about the running of the home and action plans are developed to address any issues or areas for improvement. What has improved since the last inspection? What they could do better: It would be beneficial to the residents if the home had several areas redecorated and for the renewal plan that has been developed to have clear timescales set. The home needs some investment to upgrade areas as some of the fixtures and fittings have been in place for a long period of time. Little progress has been made in achieving this plan due to insufficient investment from the provider. Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 7 The staff team need to ensure that they administer medication in accordance with the policies and procedures in place as the inspector noted that some handwritten medication instructions had not been countersigned by two people to ensure they were accurate. Some good practice recommendations have been made in relation to ensuring records are signed and dated, and for the implementation of audit systems to monitor the standards in the home and compliance with the National Minimum Standards 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.V338868.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.V338868.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): Standards 1, 2 3, and 4 (Standard 6 is not applicable in this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are fully assessed prior to moving into Pool Cottage and the people are confident that the home is able to meet their needs. EVIDENCE: A Statement of purpose and Service user guide are available in the service, and meet the required standard. The Terms and conditions of residency or contracts are developed separately depending upon the funding arrangements for that individual. The availability of these documents ensures that the residents have all of the required information to be able to make an informed decision about moving into this home, and feedback from the residents consulted and the surveys confirmed this. The discussions with residents indicated that they all feel that the service is well co-ordinated, and they are kept well informed and have access to information, help and advice. They also said that staff were “ nice, polite and helpful”; this was also supported by observations made throughout the inspection. Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 10 The three files examined contained assessments that provided sufficient information to enable the staff team to find out what people needed and what their preferences were, in order to delivery the required level of support. The staff spoken with demonstrated a good understanding of the needs of older people and all stated how they are committed to their role. They felt they received enough information, to deliver appropriate care, and received good support from the management team and positive training opportunities which assists them in meeting residents needs The Registered manager stated that she did not routinely confirm in writing that the home was able to meet the resident’s needs following the preassessment, but stated that she would now formally write to all prospective individuals. Pool Cottage Care Home DS0000061459.V338868.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): 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. Residents are involved in decisions about their lives and have an active role in the planning of their care and the support they receive, which meets their personal, health and social needs. EVIDENCE: The residents spoken with confirmed that they are consulted about the development of their plan of care and there was evidence in the files to confirm this. The staff members also understand the importance of residents being involved in this process and to be supported to take control of their lives. All three files examined contained the required documentation to provide the staff with sufficient information to meet the individual needs of residents. The files contained the required assessments to identity any risk and support requirements in relation to moving and handling, tissue viability, and falls. Improvements have been made to ensure that all of the assessment are completed in full and include the action to be taken by the staff team. However in one file where a high score was recorded following a tissue viability Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 12 assessment the action required was not recorded, but the resident did confirm that they have received aids and support in this area. (life history etc) The health care needs and arrangements for residents to access outside health care professionals and for the purposes of routine and specialist healthcare screening were generally well accounted for and records were maintained in respect of these. Residents confirmed that they are involved in the monthly reviews of their care plans and those that are able sign to say that they agree with the contents. The medication practices and storage was examined and these were found to be generally satisfactory. There was evidence to support that majority of the residents have had a medication review. Residents are consulted about the level of support they require and this is clearly recorded in their files. A couple of residents self medicate and during discussions confirmed that they have the appropriate storage and support to maintain their independence in this area. The inspector did note that a couple of handwritten medication instructions had not been countersigned by two staff members to confirm that they have been verified and that signature sample sheet was not in place. In response to the previous inspection report the senior staff now ensures that they sign the medication sheet, following the administration of the medication. There was no evidence to support that the manager has developed and undertaken a medication competency assessment in order to assess the practices of the staff following their training. Observations and feedback indicated that the staff deliver care in a manner that upholds individuals privacy and dignity, and residents stated that the staff “always knock” before entering their room. Residents stated that support is “always provided in a courteous and respectful manner”, and that they are able to exercise choice in the home such as what they can wear and how they occupy their time. It was observed that there appeared to be good relationships between residents and staff and that staff were respectful in their approach to residents. Pool Cottage Care Home DS0000061459.V338868.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): Standards 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to social, cultural and recreational activities that meet their expectations. Residents received a healthy, varied diet according to their assessed requirements and preferences. EVIDENCE: Residents confirmed in their feedback that they felt the home was relaxed and the routines were flexible, in that they were able to choose how they wished to spend their day. Residents also confirmed that they “are always consulted and given choices on a daily basis”. They also felt that staff were always willing to sit and talk with them when they had time away from essential duties. Details of entertainments and social activities were posted on the residents and relative’s notice boards and these were displayed in the form of a newsletter. A variety of in house activities were organised, including board and card games, sing-alongs and crafts. On the day of the visit residents were observed listening to records in the morning and some had their hair done by the visiting hairdresser, and some did some planting outside in the grounds. During the afternoon, some residents had their nails done and majority participated in a game of bingo. Residents have access to a library, which provides books in Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 14 large print and talking books. Residents spoke of recent trips out to garden centres and to Chatsworth, and stated that they have church services in the home and some residents attend their local church. The home has good links with the community and neighbours were observed visiting the service to say hello and spend time with residents. Residents confirmed that they have visitors whenever they chose and that they are welcomed into the home. Some residents state they go out to families and friends also as they choose. Comments from residents and information within the surveys confirmed that residents were satisfied with the meals provided. The inspector joined the residents for their lunchtime meal. The tables were set with napkins and various drinks, and the potatoes and vegetables were served in terrines to encourage resident’s to be self- managing. The meal was relaxed and conducted at the residents pace. Residents commented that the cook was aware of their likes and dislikes and does not serve them food that they do not like. The care staff were observed asking each resident their preferred choice during the morning period, and residents confirmed that choices are always offered. A number of individuals required support to eat their meals, and this was provided in a dignified manner as the staff team also had a meal with the residents. Pool Cottage Care Home DS0000061459.V338868.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): Standard 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns and have access to an effective complaints procedure. The safeguarding adults procedures and trained staff team protect their rights and safety. EVIDENCE: Residents stated that they felt able and confident to raise any concerns they had with the Registered manager, who they stated would listen and resolve any issues. Residents are aware of the procedures in place, and stated that they have no concerns at this time, and any issues they did have, they would usually raise in the residents meetings. The Registered manager confirmed that no complaints have been received since the previous inspection visit. Procedures are in place in relation to safeguarding adults from risk of abuse and around whistle blowing. These procedures link in with the local protocols. The staff members spoken to confirmed access to this training and had a good awareness of the procedures to follow, and this included all staff that work in the home and not just the care staff. The staffing matrix indicated that 7 staff members are required to undertake this training but these staff members have been highlighted to attend future courses and include new employees that have not yet started their employment. Pool Cottage Care Home DS0000061459.V338868.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): Standard 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 the environment is comfortable and safe, it is in need of some investment in order to make it a homely and a valued setting for residents to enjoy. EVIDENCE: The feedback from resident’s indicated that the home is “always clean and never smells”. One resident stated that this was one of the criteria they had during the visit to check the home out and it passed with “flying colours”. Residents felt that the environment was homely and safe but felt that it could do with an upgrade as some of the fixtures and fittings have been in place for a long time, and some areas would benefit from being redecorated as they are looking worn. This was supported by observations made during the visit. The dinning room carpet looked dirty and stained, but the Registered manager stated that it was due to be cleaned that night, however the carpet was looking worn and it was starting to fray along some of the edges. Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 17 Although a redecoration and renewal programme is in place little progress has been made in achieving the targets due to insufficient investment from the provider. The inspector was informed that new crockery was required and that some staff had donated some, until funding has been agreed for a new set. Some residents escorted the inspector to view their rooms, which were personalised with their belongings. Residents stated that they like their rooms as the views from the windows were “breath taking”, and “beautiful” as some over looked Melbourne Lake. As mentioned some of the rooms would benefit from being redecorated as the wallpaper starting to peel off in one resident’s bathroom. Residents have access to a large enclosed garden which runs around the lake and which is used by a variety of wildlife. Residents stated that they had access to various aids and equipment to support them in their mobility or in accessing the bathrooms area. Information included in the pre-inspection questionnaire indicated that one bedroom and a corridor had been redecorated and re-carpeted since the last inspection. Care staff undertake laundry tasks as part of their routine work. Residents commented that they were satisfied with the service provided and the clothes ‘were always returned in good condition”. The home has an external audit of the building that will be undertaken towards the end of June Pool Cottage Care Home DS0000061459.V338868.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): Standard 27, 28, 29, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent, stable and experienced staff team that have been recruited and vetted to ensure residents are safeguarded EVIDENCE: The number of staff on duty on the day of the inspection was consistent with the numbers identified on the staffing rota. However due to some staff being on holiday and a vacant position, both the Registered manager and deputy were working on the floor. There was also additional support from a cook, and domestic staff. The feedback from the surveys indicated that residents felt that the staffing levels were sufficient to meet their needs. Positive comments was received from the residents spoken with and within the surveys, some of these comments included: “The staff are marvellous”, ”they are very helpful and kind”, “they are always available”, and “the staff are very caring people”. During discussions with the staff members on duty, they confirmed that they were able to meet the needs of the residents, based on the current levels employed. Staff were observed supporting people with patience and sensitivity, and when possible they took every opportunity to engage them with conversation. Staff demonstrated a clear understanding of their roles and responsibilities and confirmed that they have positive training opportunities. Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 19 Three recruitment files were viewed, for staff that had been recently employed. There was evidence to support that all of the required recruitment checks had been undertaken including a check with the Criminal Records Bureau (CRB). Majority of the staff team have worked in the home for period of time and residents benefit from having a stable staff team, as they have developed good working relationships. Evidence of training undertaken was available in the staff personnel files, and a training matrix is in place. This indicated that majority of the staff team have undertaken the mandatory training subjects and those that have not yet achieved this was booked onto a future course. The staff also access training in subjects relating to the different support needs of older people. The staff spoken to informed the inspector that an induction programme is provided which includes a service specific induction and the new ‘skills for care’ induction. The pre-inspection questionnaire stated that 5 care staff have achieved a National Vocational Qualification to level 2 or above and 7 are currently undertaking this training. Pool Cottage Care Home DS0000061459.V338868.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): Standard 31, 33, 34 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. This results in practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: Residents stated that they felt they were consulted about day to day issues, and found the Registered manager to be approachable and receptive to new ideas. Feedback from the residents indicated that the home was well managed and a good rapport between the residents and the management team was observed. Staff stated that they found the management team to be supportive and provided good leadership and direction, and they confirmed access to regular supervision and team meetings. Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 21 The Registered manager and deputy are very experienced and both have recently completed the NVQ 4, and both attend the training courses with the staff team to maintain their skills and knowledge. The home had several quality assurance measures in place, including residents meetings, satisfaction questionnaires for residents, and their relatives in order to measure the success of the home in meeting its stated aims and objectives. The Registered manager does not usually complete a report of the findings of the questionnaires but following discussions with the inspector stated that she would now complete this. Discussions were also had about internal measures to monitor the quality and safety of the environment, which was recently undertaken and an action plan developed, however the provider has not yet agreed to the funding of replacing and implementing the action plan in order to improve the areas identified. The Registered manager intends to look at other internal audit systems in order monitor the general running of the home. The inspector examined the Residents finances, which are managed through a computer system, and each resident has their own finance sheet detailing all of their transactions. The systems in place were clear and easy to follow with a effective audit trail in place. Staff files indicated that staff have undertaken training in mandatory health and safety subjects or are due to attend courses. A recent fire and Environmental Health inspections have been undertaken and requirements have been made. The pre-inspection questionnaire indicated that all of the records for the Health and Safety monitoring and the servicing of systems and appliances were up to date. There was evidence to support that the provider undertakes regular visits to the home and completes a report of the findings in accordance with the regulations. Pool Cottage Care Home DS0000061459.V338868.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 3 3 3 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 2 3 X X 3 Pool Cottage Care Home DS0000061459.V338868.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 OP1 Regulation 14 (d) Requirement Timescale for action 01/09/07 2 OP9 13(2) 17(1a) Sch 3 13 (6) 23 (2) (b) 3. 4. OP18 OP19 The Registered manager must confirm in writing whether the home is able to meet a residents needs following the preadmission assessment. This is to ensure individuals are aware of the outcome of the assessment. Two staff must check and sign 01/09/07 handwritten medication instructions to ensure they are accurate with the prescribed instructions. The 7 staff identified must attend 01/11/07 safeguarding adults training. training must be arranged The renewal and redecoration 01/09/07 plan must have clear timescales and sufficient investment in order achieve the targets identified and achieve the upgrade of several areas of the home. Pool Cottage Care Home DS0000061459.V338868.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 4. Refer to Standard OP7 OP8 OP27 OP33 Good Practice Recommendations All of the records in the care files should be signed an dated (were possible) by the staff and the resident The action taken in response to the outcome of a high score on the tissue viability assessment should be recorded. The staffing rotas should include the roles the staff undertake. A report should be completed of the findings of the resident’s quality assurance questionnaires. Audit systems should be implemented to monitor the standards in the home. Pool Cottage Care Home DS0000061459.V338868.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V338868.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. 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!