Inspection on 27/09/05 for The Cottage

This inspection was carried out on 27th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Cottage 05/02/09

The Cottage 02/11/06

The Cottage 14/02/06

The Cottage 08/03/05

The Cottage 05/08/04

The Cottage 23/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Cottage 51/53 High Street Brightlingsea Essex CO7 0AQ Lead Inspector Kathryn Moss Announced Inspection 27th September 2005 09:30 The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 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 The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 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 Adults 18-65. 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. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Cottage Address 51/53 High Street Brightlingsea Essex CO7 0AQ 01206 303676 01255 821629 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) Mr Roy Bellhouse Mr Roy Bellhouse Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: The Cottage is a registered care home based in a detached grade 2 listed period property situated close to Brightlingsea town centre. It has six single occupancy bedrooms and two double bedrooms, two communal lounges and a dining area, kitchen and laundry facilities, two bathrooms and a shower room, plus additional toilets. The home has front and rear access, with a side parking area that links, on to the rear garden. The Cottage provides 24-hour residential care and accommodation for up to ten adults with learning disabilities, both male and female. The home is not suitable for anyone with mobility difficulties as access to the first floor is by stairs only, there are no assisted bathing facilities, and the accommodation does not have level access throughout. The home is owned and run by Mr Roy Bellhouse and Mrs Lynda Bellhouse, with Mr Bellhouse being the registered provider and the registered manager. For the purpose of this report, the term ‘proprietor’ has been used to denote information provided by either proprietor during the inspection. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on the 27/9/05, lasting seven and a half hours. The inspection process included: discussion with the proprietors and three staff; discussion with five residents; the viewing of communal areas; and inspection of a sample of staff and resident records. As part of this inspection, feedback questionnaires were completed by two relatives and by six residents. 23 standards were inspected, and 3 requirements and 7 recommendations have been made. There were 10 people living at the home on the day of the inspection, many of whom were out for all or part of the day. The residents and relatives consulted as part of this inspection were all very positive about the staff team, support and lifestyle provided at The Cottage. What the service does well: What has improved since the last inspection? The home had made good progress towards meeting all of the requirements identified at the last inspection, which is to be commended. In particular, the home had made excellent progress in the development of care plans, which had now all been updated to include clear and detailed information on each person’s strengths, wishes and needs, and the staff team had made very good progress towards achieving their NVQ qualifications since the last inspection, and should be congratulated on this. A number of environment issues had also been addressed (e.g. locks on doors, new medication cabinet, new washing machine, extra electric sockets, etc.). The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 6 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 Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The home has appropriate information available to prospective residents to enable them to make an informed choice about living at the home. The home can demonstrate that it has the skills and facilities to meet people’s needs and aspirations. EVIDENCE: The home has a ‘statement of purpose’ and a ‘service user guide’, as required by Regulation and seen at the time of the last inspection. The proprietor had made amendments to the home’s statement of purpose since the last inspection, which now included actual room sizes and made reference to the fact that the building is not accessible to wheelchair users. Following a requirement at the last inspection, the proprietor had provided each resident with a copy of the inspection report, in addition to the copy available in the home. They were advised that the service user guide should still include information on the inspection report (e.g. where it can be accessed) as this is referred to in Regulation 5 of the Care Homes Regulations, and the service user guide is a document that would need to be provided to prospective residents. As there had been no new residents since the last inspection, the assessment of prospective residents could not be assessed on this occasion. The home continued to demonstrate that it was able to meet the needs of the people who it aims to accommodate: this was evident through service user plans, staff training and discussion with staff and residents. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Residents’ needs and goals are reflected in their Individual Plans. The home assists and encourages residents to make decisions about their lives, and to participate in all aspects of life in the home. The home assesses and supports residents to take reasonable risks as part of promoting their independence. EVIDENCE: The home has an assessment form that goes through each person’s strengths and needs, and this is reviewed every six months. This forms the basis for the development of each person’s Individual Plan, which is also reviewed every six months by the proprietor and key worker, in conjunction with the resident and any other relevant parties (e.g. care manager, if involved). The home had done extensive work on Individual Plans over the last year, and had now updated all residents’ plans. Two plans were viewed, and the information they contained was now very comprehensive, covering all aspects of the person’s daily life and providing detailed information on their strengths, needs and wishes in each area of daily life, and on the action required of staff. The proprietors and staff are commended on the quality of these documents. There were also some separate care plans addressing specific short and longterm aims. It was confirmed that where residents are able, they are actively The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 10 involved in their care planning and are encouraged to read their files. Individual Plans are not currently signed by residents (where able), and it was recommended that this could be done to demonstrate their involvement. Individual Plans are not at present available in alternative formats. Staff promoted and encouraged residents to make decisions about their daily lives: this was observed in small ways on the inspection (e.g. asked where they wanted to eat their lunch), and other examples were discussed (e.g. how residents were provided with information and assistance to choose college courses, etc.). The home holds regular residents’ meetings, and the minutes of these showed that residents were consulted on issues relating to the home, and contributed suggestions (e.g. re meals, outings, college courses, etc). Residents spoken to were confident and assertive, and it was good to see them expressing their ideas and views. Staff related well to the residents, involving them in day-to-day conversations and decisions, and encouraging their participation in daily tasks. Advocacy support has been accessed for individual residents when required. A range of the home’s policies and procedures were available to residents, although only a few documents were currently available in alternative formats (e.g. a protection of vulnerable adults document was available with pictorial support). Only one resident currently manages their own finances, and the proprietor is the appointed agent for other residents in relation to their state benefits: records of residents’ finances were not inspected on this occasion. Individual risk assessments were present on the two files inspected, covering risks relevant to those particular individuals; these cross-referenced to their Individual Plan, and showed action taken to minimise the risk. Each file contained a copy of the home’s missing person’s procedure, and a profile of the person in case the information was needed for this purpose. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 and 17 The home provides and supports opportunities for residents’ personal development, and for them to take part in appropriate activities (including leisure activities) and to become part of the local community. The home provides and promotes a healthy diet and enjoyable meals and mealtimes. EVIDENCE: The home provides a variety of opportunities for residents to maintain and develop social, emotional, communication and independent living skills. Examples of these opportunities include: support to attend outside activities, courses and social clubs; encouragement to participate in the day-to-day running of the home by contributing ideas and assisting in tasks; encouragement to deal with anxieties and conflicts through communication; the promotion of independence through risk assessments and appropriate support from staff; and assistance to meet spiritual needs. None of the residents were engaged in any paid or voluntary work at the time of this inspection. However, all those spoken to were positive about the activities they participated in, and were talking about the new college courses The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 12 they had just started. Nine of the residents were enrolled on different courses, including: cooking, computing, flower arranging, drama and a ‘speak up for yourself’ class. On the day of the inspection most residents were out of the home for all or part of the day, and mealtimes were seen to be flexible to accommodate this. Staff confirmed that staffing was provided flexibly to support residents’ needs and choices, including at evenings and weekends. The home promoted an individual, person-centred approach to supporting people’s choices and interests. Residents spoken to had been on holiday together earlier in the summer, and had clearly enjoyed this. The home makes good use of the local community, accessing local shops, pubs, churches and other facilities; staff were in the process of applying for bus passes for residents, to enable more use of local transport. The home is involved in the local community, and residents were enthusiastic about helping to organise a forthcoming coffee morning to raise money for a cancer charity. The home operates a rotating four-weekly menu, based on residents’ likes and preferences, with other options available at all times. The menu showed a good range of balanced meals, and residents were positive about the meals and seemed to enjoy these. Snacks were seen to be available during the day. Meal times were seen to be flexible to fit in with individual plans for the day, and where able, residents were encouraged to assist with the preparation and serving of meals. Staff had recently completed a distance training course in Nutrition and Health, and had found this helpful; staff showed an awareness of residents’ nutritional needs, and instances when this required monitoring were discussed. Assistance with eating was provided when required. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 At the time of this inspection, personal support was provided in a way that met residents’ preferences and needs, and the home was meeting residents’ health needs. Appropriate medication practices were in place to protect residents; however, documentation did not fully evidence these practices. EVIDENCE: Individual Plans clearly described any support required by residents with their personal care and mobility, emphasising what they could do for themselves. As noted in the section on Individual Needs and Choices, plans contained good, detailed information on personal care needs, including people’s likes and dislikes. Residents were appropriately dressed, and staff supported residents to choose and buy clothes and to follow their individual preferences and styles. Residents were happy with the support received from staff, and were very positive about all the staff. Staff demonstrated a good knowledge of residents’ needs and abilities. The home operates a key worker system, and residents were consulted on who their key worker was. Where possible, key workers were appropriately matched to residents with respect to age, gender, interests, etc. External specialist support was accessed when required (e.g. CPN, psychiatrist, etc.), The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 14 and their advice incorporated into the way care was provided. Daily routines, and assistance required with these, were observed to be flexible. Files contained records of contact with healthcare professionals, and individual care plans indicated any support needed with healthcare issues. Good information on one individual’s epilepsy was seen on their file, including action required by staff. There was evidence that staff monitored healthcare needs, sought appropriate advice and input if required, and supported residents to attend appointments. Annual health checks were not discussed on this occasion. The home had produced a medication policy since the last inspection, as previously they had a variety of relevant guidance but no specific procedure describing the system on the home. This was inspected and was seen to be a good initial policy document, but needed further development to fully cover all aspects of the management of medicines in the home (e.g. recording medication received at or leaving the home; protocol for administering and recording any non-prescribed medication; procedure for self-administration; reference to management of any controlled drugs; etc.). It was noted that no residents have responsibility for administering their own medication at present. The home had obtained a medication cabinet since the last inspection, which had improved medication storage arrangements. The proprietor was advised to monitor the temperature of this cabinet, to ensure medicines are stored at below 25°C. The home does not have a controlled drugs cabinet, but no controlled drugs are currently in use in the home. The proprietor was advised to seek a pharmacist’s advice on storage arrangements if anyone is prescribed a controlled drug in future. It was noted there were bottles of medicines in the cabinet that had not been dated on opening; this should be addressed. Clear records of current medication for each resident were maintained, both in their individual plans and on a Medication Administration Record (printed by the dispensing pharmacist. These were viewed and seen to record all medication received by the home, and medication administered. Records of medication administered were generally well maintained, with omissions noted on just one day. Where no new medication had been supplied, medication carried over from the previous month was still not being recorded on the new MAR, and it was also noted that handwritten entries or changes to information recorded on the MAR were not being signed and dated by the person making the entry. The proprietor was advised to ensure this is addressed. The proprietor confirmed that all staff had previously received medication training, and that two staff were due to attend an update. Evidence of medication training was not inspected on this occasion. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home’s procedures and practices ensure that residents are able to express concerns, are listened to, and are protected from abuse. EVIDENCE: The home had a clear complaints procedure, covering all relevant information. No complaints had been received by the home in the last year. Residents spoken to were confident and outspoken, and the home encouraged residents to share ideas and concerns. The six residents who completed feedback questionnaires as part of this inspection all stated that they would know who to speak to if they were unhappy with their care. At the time of the last inspection, the home had a copy of the Essex Social Services guidance on the Protection of Vulnerable Adults (POVA), but no specific policy/procedure for the home. The proprietor had since developed a POVA policy for the home: this was a clear document, but needed to include details of local multi-agency procedures, including referral to social services and the police. Although staff had not attended formal POVA training, an inhouse session had been attended by all staff within the last year, all staff had received a copy of the Essex ‘Protecting Vulnerable Adults’ booklet, and most staff were doing NVQ level 2 which incorporated a unit on POVA. The home had some information on protection from abuse in pictorial format for residents: residents spoken to were positive about the staff, and those who had completed feedback questionnaires all stated that they felt safe in the home. The home had clear procedures for handling residents’ monies (practices and records were not inspected on this occasion), written procedures precluding staff involvement in making or benefiting from residents’ wills, and a Management of Violence policy. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None No Environment Standards were specifically inspected on this occasion. EVIDENCE: Although Environment standards were not specifically inspected, it was noted that key issues raised at the last inspection had been addressed. The proprietor confirmed that additional electric sockets had been installed in several bedrooms, three bedrooms now had locks on the doors (for residents who were able and safe to use these), the bathroom door locks had been changed to enable staff to override them from the outside, paper towels were provided in bathrooms and in the laundry, and a new washing machine had been obtained to ensure a wash cycle of 65°. An infection control procedure for the home had also been developed, and a risk assessment on the handling and cleaning of soiled laundry. The proprietor is commended on the prompt action taken to address these previous requirements and recommendations. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The home has a stable, competent staff team who are achieving the relevant qualifications, and are provided with appropriate training. The staff team is effective in the way it supports residents’ individual needs, and the residents benefit from staff being well supported and supervised. The home operates recruitment practices that protect residents. EVIDENCE: The home has a consistent team of staff, who have all been working at the home for many years. The staff rotas viewed showed sufficient numbers on duty to meet residents’ needs, and staff reported that staffing was flexible to ensure an appropriate skill mix and number of staff to assist with activities at different times of the day and week. Weekly staff signing-in sheets showed the staff working in the home at any time and the person in charge of each shift. Staff observed during the inspection appeared to communicate appropriately and effectively with residents, none of whom currently used any other methods of communication. The proprietor reported that staff meetings were held in the home (records were not viewed on this occasion). Recruitment practices could not be fully inspected on this occasion, as no new staff had been recruited for some time. However, it was noted that CRB checks had been obtained for al existing staff, and a sample of files viewed contained appropriate evidence of identification and contracts of employment. The home had recently revised its application form, which was noted to contain space to The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 18 record the person’s employment history (and to explain any gaps), names of referees (including the last employer), and a declaration of criminal record. For new staff recruited, the need to obtain a clear statement of the individual’s health (fitness to do the job) was discussed with the proprietor. It was confirmed at the last inspection that the home had an induction programme for new staff that met the TOPSS specification. The proprietor confirmed on this inspection that they had also obtained information on the Learning Disability Award framework training. Core training needs were identified in the home’s annual development plan. All care staff were currently doing NVQ level 2 in care, apart from two seniors who were due to do the Registered Manager’s Award and one person who already had an equivalent qualification. Staff doing NVQ level 2 had made good progress and were due to complete this training by the end of October 2005. Most staff had also completed distance-learning courses in Food Hygiene and in Nutrition and Health this year. Evidence of staff training took the form of certificates on staff personal files; a training file contained individual staff training profiles, but these were not up-to-date. Evidence of certificates on a sample file viewed showed a good range of relevant training, covering both core training issues (e.g. fire prevention, first aid, medicines, health and safety), and specialist issues (e.g. epilepsy, disability equality, nutrition and health). It was noted that all residents were independently mobile, although one needed some supervision and support; staff tasks also involved the handling of loads (e.g. shopping, household equipment, etc.). The sample file viewed did not contain evidence of moving and handling training, and the proprietor should ensure that staff attend regular updates in this subject. The home has a small stable staff team, and the proprietors are regularly present working alongside staff in the home. There is therefore good, ongoing support and supervision of staff, and staff spoken to felt well-supported in their work. Formal individual supervisions take place monthly and are recorded, with good evidence seen on a sample file viewed; three monthly appraisals also take place (evidence not viewed). The home has a grievance procedure that is available to staff (disciplinary procedures were not viewed on this occasion), and also had a procedure for staff on dealing with aggression (Management of Violence policy). The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 40. The home is managed by people with appropriate experience, and residents’ benefit from a well-run home. The home seeks residents’ views on the service they receive; residents appeared confident that their views were listened to. EVIDENCE: The registered manager is also the proprietor and registered provider of the home. Both proprietors demonstrate that they are experienced and competent to run a care home, are knowledgeable in both management and care issues, and show very good understanding of the needs of their residents. The registered manager is not currently undergoing NVQ level 4 in management and in care, as the proprietors are progressing plans for two of the senior staff to do this training with a view to them taking over the registered manager role within the home. The proprietors also complete training appropriate to updating their skills and knowledge. Service users are consulted on day-to-day issues on an ongoing basis, both informally and through residents’ meetings, and it was clear that they had a ‘voice’ in the home. The home had also implemented a new service user The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 20 feedback questionnaire this year, which contained a good range of questions with pictorial support. This had been completed by all residents this year, and it was good to see that responses were all very positive. Staff had assisted those who could not complete these independently, and it was noted that in some instances staff had recorded a response to a question that a resident may not have had the capacity to fully understand. Whilst this was based on staff knowledge and understanding of the resident, the proprietor was advised to explore alternative ways of supporting residents to complete these in future (e.g. advocate, relatives, etc.), to avoid assistance being provided by the staff who also provide the care. The home had also sent out questionnaires to residents’ families, but had not had much response to these. The home produces an annual development plan, and the plan for 2005 was seen to include some clear aims and targets for relevant issues (e.g. premises, care, training, etc.). The proprietor stated that they have not previously formally reviewed and recorded whether the objectives in the annual development plans have been achieved, and it was recommended that this be done in future. The home does not currently produce any report on the outcomes of service user surveys or the review of the quality of the care provided at the home. Residents had clearly been told about the announced inspection, and the home had made very good progress with actioning the requirements from the previous inspection report. Policies and procedures were not viewed in detail on this inspection, but the proprietor had made good progress in producing specific policies and procedures highlighted at the last inspection (e.g. medication, POVA, infection control, etc.). The proprietor was advised to ensure that these are signed and dated by the registered person, and are reviewed regularly. Health and safety issues were not fully inspected on this occasion, but it was noted that appropriate action had been taken to implement written risk assessments since the last inspection. The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Cottage Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000017960.V253987.R01.S.doc Version 5.0 Page 22 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 YA20 Regulation 13 Requirement Timescale for action 31/10/05 2 YA20 13 3 YA39 24 It is required that the home’s medication administration policy/procedure covers all aspects of the receipt, storage, recording, administration and disposal of medicines within the home. It is required that staff sign and 14/10/05 date any handwritten entries or changes made to medication administration instructions on the MAR forms. This is a repeat requirement (last timescale 31/5/05). It is required that the registered 31/03/06 person supply the CSCI with a report on any review of the quality of care carried out in the home (e.g. a survey of residents’ views), and make a copy of the report available to residents. (See also recommendation 7). This is a repeat requirement (last timescale 30/6/05). The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 23 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 Good Practice Recommendations Standard YA6YA8YA40 It is recommended that the home explore whether any key policies and documents (including care plans) could be produced in alternative formats to make them more accessible to residents (e.g. audio, video, pictorial, etc.). YA20 It is recommended that where no new medication is supplied by the pharmacist and a new MAR form is started, staff record any remaining medication carried over from the previous month on the new MAR. YA23 The registered person should ensure that the home’s procedure for responding to suspicion of abuse includes details of local multi-agency protocols (i.e. referral to social services and the police). YA23 It is recommended that staff attend formal POVA training. YA35 It is recommended that clear individual staff training profiles (records) are maintained, and that these include details of all training attended by staff (formal and informal). It is recommended that all staff receive updated training in moving and handling. It is recommended that the registered person monitor and review whether the objectives and goals of the home’s annual development plan have been achieved, and that this information is incorporated into a report on the review of the quality of care in the home (see requirement 3). 2 3 4 5 6 7 YA35 YA39 The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cottage DS0000017960.V253987.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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