Care Home: Coombe End

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What the care home does well Planned admissions to the home are well managed and minimises the potential risk of someone being admitted to the home whose needs cannot be met. There are some excellent care plans developed in picture format to enable people with communication difficulties to understand the document more easily. There are some excellent care plans for people`s personal care written in great detail to enable staff to meet people`s needs consistently. People lead active lifestyles supported by staff. A completed survey stated, "In a difficult and challenging environment the staff team meet the needs of the people in the home as best as they are able". Another completed survey commented, "The staff are very caring". What has improved since the last inspection? Care plans have been re-written since the previous inspection was completed and now provide staff with greater detail to enable peoples needs top be met. The range of activities completed by people in the home has increased. The environment of the home has improved and now provides people living there with a more homely and comfortable place to live. CARE HOME ADULTS 18-65 Coombe End 184 Hucclecote Road Gloucester Gloucestershire GL3 3SJ Lead Inspector Mr Paul Chapman Key Unannounced Inspection 9 and 29th April 2008 09:00 th Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 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 Coombe End DS0000067015.V358916.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 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. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe End Address 184 Hucclecote Road Gloucester Gloucestershire GL3 3SJ 01452 617193 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) www.brandontrust.org The Brandon Trust Post Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability -Code LD The maximum number of service users who can be accommodated is 5. 2. Date of last inspection 6th June 2007 Brief Description of the Service: Coombe End is a large two-storey house in a residential area about two miles from Gloucester city centre. The service provides accommodation for adults with learning disabilities. The home is centrally located within the community of Hucclecote close to local amenities. There are bedrooms on the first floor and further bedrooms on the upper floor. All the room(s) are adapted to meet the needs of the residents and this includes specialist equipment when necessary. The home is run by Brandon Trust and Advanced Housing manage the property. Accurate information about fees was not obtained during this site visit. Fees vary dependant on the needs identified by the completed assessments. The home is able to provide a Statement of Purpose, terms and conditions and Service User Guide on request to any potential residents. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place in April 2007 and included two visits to the home on 9th and 29th April. The acting manager was not present at the 1st day of the site visit and it was agreed that we would return on the 29th of April to meet them. An AQAA (Annual Quality Assurance Assessment) has been completed as part of the inspection process. Time was spent observing the care of people and their interactions with staff. 1 person living in the home was spoken to and their room was seen on their invitation. We received completed questionnaires from 6 staff, 1 health care professional, 1 relative and 1 person living in the home. The care of two people was looked at in depth that included looking at their financial, medication and personal records. Four staff were interviewed about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: What has improved since the last inspection? Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 6 Care plans have been re-written since the previous inspection was completed and now provide staff with greater detail to enable peoples needs top be met. The range of activities completed by people in the home has increased. The environment of the home has improved and now provides people living there with a more homely and comfortable place to live. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 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 Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Since the emergency admission to the home staff have completed a thorough assessment of the person’s needs and the care plans produced as a result enable the person’s needs to be met effectively. The other admission procedure has been well managed and has enabled the person to have a smooth transition into the home. EVIDENCE: Since the previous inspection was completed 2 people have been admitted to the service. One admission was made as some what of an emergency which limited the information the service received before the person moved in and meant they were unable to “test drive” the service. Since the person has been living in the home staff have completed an assessment of the person’s needs and developed care plans to address those needs. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 9 It is recommended that the service’s Statement of Purpose is reviewed to ensure that it reflects that the service will take emergency admissions. The 2nd admission to the service was from another home within the organisation. Records showed that the service had received a completed community care assessment from the person’s social worker, the person had visited the home on numerous occasions before a decision was taken to move in, and the person’s key worker from the other home was seconded to work in this service for a period of time. All of these elements have led to the person having a smooth transition into the service. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s care plans provide staff with sufficient information to enable them to meet people’s assessed needs consistently. The service provided in the home is led by the needs of the people living there. Risk assessments identify and minimise potential risks to people. EVIDENCE: We examined in detail the information relating to the individual needs and choices for 2 people in depth. The previous inspection report made 2 recommendations against standard 6. These were to review the system of reviewing care plans and to archive a significant amount of information stored in people’s files. Examination of people’s files showed that both of these areas had been addressed. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 11 All people living in the home have key workers. Both files provided information to the reader under specific topics. Both people had pen pictures which provided “a flavour of life”. Both people were asked how they like to be known, and chose to abbreviate their names. During the site visits staff were seen to be following people’s wishes and they were calling them by their preferred names. Each person had a completed document named “12 activities of daily living”. The completed documents provided staff with information including: • Sleeping and resting • Breathing • Personal hygiene • Eating and drinking • Expressing sexuality • Mobility • Communication • Leisure • Eliminating • Safe environment • Controlling body temperature Reading these documents showed that staff completed each section with input from the person. Each section stated what the person would do for themselves and what staff support was required to enable their needs to be met. A shortfall identified with this process was 1 of the documents wasn’t dated when it was written. Another document that provided the reader with good, helpful information was the likes and dislikes (strengths and weaknesses) document. As well as highlighting a range of activities people liked it also identified what food people enjoyed. Both of the files seen contained funding authority care plans and a range of care plans created by the staff. These included: • Bathing • Showering • Washing • Use of toilet • Sleeping • Medication • Activities • Communication • Mobility Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 12 All but 1 of the care plans seen provided an excellent level of detail to staff about what input was required to meet the person’s needs. 1 person’s medication care plan could be made clearer as when reading it it is not clear whether staff support them to administer their medication or they do it themselves. This was brought to the attention of the acting manager. A good practice identified in the care plans was that they clearly stated that the person should be asked to complete as much of the task themselves as possible. In addition to the written format for care plans staff have started to develop care plans written in “first person” and using photos to describe each step of care. This is at an early stage of development at present but is good practice enabling people with communication difficulties to understand their plans of care. With all of the care plans recently being re-written by staff they were not due for review. It is the aim that reviews will take place as and when required, but at a minimum they will be reviewed quarterly. Since the previous inspection was completed staff have started to write monthly summaries of significant events and activities completed by people living in the home. These documents record care plan reviews, risk assessments, medication changes, health care visits, accident forms and activities offered and refused. We were able to find completed forms for 1 person, but unable to the forms for the other person. This was brought to the attention of the staff on duty. Whilst completing the site visit we observed the interactions between staff and people living in the home. Relationships were seen to be respectful with people being asked what they would like to do and staff providing support where required. Speaking to 1 of the people living in the home they explained that although “its not the sort of place I want to live the staff have been really good and help me”. The staff have been supporting the person to move to their own flat. Risk assessments were seen for both people. The assessments seen highlighted what the risk was and identified steps to minimise those risks. There were a good range of assessments in place but some shortfalls were highlighted and brought to the attention of the acting manager. 3 risk assessments had been roughly written up and were not dated, additionally we were unable to find 2 risk assessments: • In 1 person’s activity care plan it identifies a risk assessment for using the home’s vehicle and we were unable to find it. • We were also unable to find a risk assessment for a person accessing the local community. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 13 When speaking to the acting manager about this they said that it would be addressed. All of the risk assessments seen had been reviewed at regular intervals. The staff member supporting us explained that currently people’s Person Centred Plans are being updated and at the next site visit we will look at these. Person Centred Plan - Commonly known as a PCP, this approach empowers people to make changes in their lives, achieve their goals and ensure that resources are in place to meet their future needs. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home lead active lifestyles supported by staff where required. People’s rights are respected and care plans ensure that staff do this in a consistent manner. People living in the home are offered a choice of meals and food. EVIDENCE: We spoke to people living in the home, examined records and spoke to staff about the activities they regularly take place in and outside the home. One person living in the home has their own vehicle and staff confirmed that the vehicle is only used by that person. The home has its own transport and other people living in the home use this when they go out. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 15 The records we examined for 2 people living in the home contained care plans for the activities they like to take part in. These care plans showed that they liked to complete word searches, go to the pub for a drink, out for drives in the car, go to the cinema, attend a local social club, do tapestry, play board games, have massages, attend hydrotherapy, watch TV and listen to music. Records showed and staff and 1 person living in the home confirmed that these activities take place regularly. In addition to these activities people use local facilities in Gloucester and the surrounding areas to go shopping, etc. Monthly summary sheets showed that in the previous 4 months 1 person had been on a trip to Devon, been out walking in the Forest of Dean, out in the Malverns, to a concert in the town hall, Evesham country park, Pittville Park and Tewkesbury. Staff explained that a 7- day holiday in Dorset has been booked for 1 of the people living in the home. One of the care plans we examined highlighted the need for staff to recognise and respect 1 person’s sexuality. The plan gave staff clear instructions on how this should be done. This is good practice and the care plan highlights the need for staff to respect the person’s privacy and rights. Family and friends are welcome to visit the home. We looked at the menus which showed they were run on a 4-week rota. Menus showed that people are offered 3 meals a day and a good variety of food is offered. The menu is reviewed periodically with the last review being completed in October 2007. We spoke to 1 person who said, “the food is really nice here” and, “if I want something else to eat I can choose something else”. One person has a care plan and risk assessment to address their eating and drinking needs. This was a detailed plan (making good use of pictures) written in February this year and had been reviewed monthly. The risk assessment in place had been completed with the local Community Learning Disability Team (CLDT). Speaking to the acting manager they explained that the dietician has now discharged the person. The acting manager must ensure that this is reflected in the risk assessment. A recommendation of the previous inspection report was for staff to develop a system that allows people to have more choice about their food. This has not been achieved as yet, and as a result this recommendation will be carried over in this report. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal care needs are clearly identified and guidelines ensure that staff clearly understand what they need to do to meet people’s needs. Medication administration is effectively managed and this minimises potential risks to people living in the home. EVIDENCE: Both of the people whose care we examined in detail had excellent care plans to meet their individual personal care needs. The care plans seen provided extensive information about each person’s wishes and what staff had to do. One care plan was produced in both written and picture format. Speaking with 1 person they explained that staff had spoken to them about their care plan and they were happy with how their care was delivered. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 17 The home makes good use of other health professionals to meet people’s needs where it is judged they are unable to. Both files provided good evidence of people attending doctors and dentists, etc. The previous inspection report made a requirement that each person has a healthcare assessment completed. This has not been completed but it is made a recommendation of this inspection report that the acting manager ensures that this is done. Medication administration was examined in detail and showed that the staff follow good practices to ensure that people are not put at unnecessary risks. A minor shortfall highlighted by this site visit was that the topical creams and cough mixtures should be labelled with the date they are opened. 1 person living in the home has their medication administered covertly in their food. In the past the home has completed a “best interest” document to support this practice. This document involves a multi-disciplinary meeting to discuss the reasons for the covert approach to administering medication and identifies whether it is in the person’s best interest. This document was seen to be in place and we spoke to the manager about the Mental Capacity Act and its effect on the best interest document. It is recommended that the manager investigate whether this document needs to be reviewed bearing in mind the detail of the Act. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and staff showed a good awareness of how to support people who may not be able to use it and communicate their complaint in other ways. Records of income and expenditure minimise potential risks to people who are unable to manager their own finances. EVIDENCE: The home has a complaints procedure and speaking to 1 person they were clear about who they would speak too if they were unhappy. No complaints have been to the acting manager or the CSCI since the previous inspection was completed. We spoke to staff about other indicators to show people may be unhappy if they were unable to communicate verbally. Staff showed a good awareness of how people may show they were unhappy and clearly understood what they should do to support a person in that situation. We examined records of income and expenditure for people living in the home. This showed that staff check each person’s finances at the end of a shift, that receipts are obtained whenever possible and that at the time of this site visit records were correct for the 2 people we checked. The home has a Safeguarding Adults procedure which was reviewed in October 2007. At the time of this site visit 11 staff were due to complete training in safeguarding adults. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the building does not meet people’s current needs it is now more homely, fresh and clean. EVIDENCE: There are plans for this service to be completely re-developed in the future with the aim of the people currently living in the home to have purpose built accommodation. There is no timescale for this at present. Since the previous site visit was completed we have met with the provider of this service and the housing association to discuss improvements to the accommodation. At the previous inspection we were unhappy with the standard of the accommodation being provided. As a result of these discussions the housing association have completed a substantial amount of work decorating communal, bath and bedrooms around the home. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 20 As a result the requirements against standards 24, 27 and 30 have been addressed. In addition to this new furniture and fittings have be provided. As a result the requirements against standards 24, 27 and 30 have been addressed. The home now looks much more homely and fresh. 1 person invited us to see their bedroom. It nicely decorated and personalised with their possessions. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are supported by staff with the appropriate skills to meet their current needs and minimise potential risks to them. EVIDENCE: The acting manager has completed an audit of the staff training over a period of 12 months from April 2007. Records showed that the majority of staff have completed training in areas including fire safety, epilepsy, peg feeding, food hygiene, supervision, Safeguarding adults, manual handling and first aid. The acting manager stated that currently 8 staff are either completing, or have finished their NVQs (National Vocational Qualification) in care. The acting manager stated that they Brandon Trust have just released the training programme for this year and he intends to speak to staff during supervision sessions. Staff spoken with during the 1st day of the site visit confirmed that supervision is taking place regularly with the acting manager. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 22 The acting manager stated that the Brandon Trust are currently completing a programme of training in equality and diversity for the managers. In discussion with the manager we recommend that the staff team are also enabled to complete training in equality and diversity. Staff files were examined and seen to be in order meeting the criteria of the regulations. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Significant improvements have been achieved by the acting manager and his team since the previous inspection was completed and this has resulted in better outcomes for people in the home. Health and safety procedures are followed and this minimises potential risk to people living in the home. EVIDENCE: Since the registered manager retired last summer the service has been manager by a manager registered with the CSCI who manages 1 of the organisation’s other homes in Gloucestershire. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 24 We have been in contact with the organisation about the future arrangements for management of the service, and these discussions continue. We acknowledge that there have been significant improvements in the home since the previous inspection was completed and this is reflected in this report. Speaking with staff they were positive about the influence of the acting manager since they began at the home. The only criticism was that staff felt they would benefit with the acting manager being at the home more as his time is currently split between 2 homes. It becomes a requirement of this report that the organisation put a candidate forward for registration with the CSCI. The home has a quality assurance system and the acting manager reviews a number of key standards and set goals for improvements. The manager must continue to be mindful that the system enables review of practices and continuous improvement. In addition to the quality assurance system the provider completes visits as required by regulation 26 of the Care Homes Regulation 2001. The home’s policy and procedure file was dated as being reviewed in October 2007. Records for fire safety equipment being checked/tested showed that the home’s fire alarm is being tested weekly by staff, emergency lighting is being tested monthly and an evacuation was completed in March 2008. Qualified engineers tested the system in January 2008. COSHH (Control of Substances Hazardous to Health) data sheets are available for the selection of cleaning chemicals used in the home. Fridge and freezer temperatures are recorded twice daily, and a food probe is used to check the temperatures of food being served. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 2 2 X 2 X 2 3 X 3 X Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 26 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 YA37 Regulation 8 Requirement The organisation must put a suitable candidate forward to become a registered a manager with the CSCI. Timescale for action 29/08/08 2. YA39 24 The home must have an effective 07/09/08 quality assurance system that enables review of practices and continuous improvement. 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 YA1 YA6 YA17 YA17 Good Practice Recommendations The home’s Statement of Purpose should reflect that the home will accept emergency admissions. All documents should be dated when they are created. The person’s food and drinking risk assessment should reflect that the dietician has now discharged them. A system that allows people living in the home to have DS0000067015.V358916.R01.S.doc Version 5.2 Page 27 Coombe End 5. 6. 7. 8. YA19 YA20 YA23 YA20 more choice about the food they eat must be developed. A health assessment should be completed for each person. Topical creams and cough mixtures should be dated when they are opened. The staff team should complete equality and diversity training. The implications of the Mental Capacity Act should be investigated in relation to administering 1 person’s medication covertly. Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coombe End DS0000067015.V358916.R01.S.doc Version 5.2 Page 29 - 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!