Care Home: Coombe Oak

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What the care home does well People who use the service told us "I like living here", "I like my room, I have everything I need" and "I think the staff are great", "they help me" and "they are good cooks here". No one who uses the service made negative comments about the service or staff either directly to us or through the surveys we provided. We observed very good levels of communication between staff and people who use the service. Individuals told us that they felt staff listened to them and acted on what they said. Staff were observed to respect the privacy and dignity of individuals throughout this inspection. Staff keep the needs of individuals under review and adjust the levels of support for individuals as needed. Where anyone expresses a wish to move to more independent living this is taken seriously by staff and action is taken to investigate how this can be achieved. People who use the service are encouraged to follow their own interests and offered opportunities to try new things. The range of activities available is good. Throughout this inspection we saw staff offering informed choice to people who use the service in all aspects of daily living. What has improved since the last inspection? There is now more emphasis on individuals following interests and activities outside the service. Staff and people who use the service felt that the reduced use of day centres has produced a real improvement in the quality of life of individuals. Improvements have been made in the care planning and review process which assists in ensuring that individuals receive the support they need in the way they wish. All staff who administer medication have been provided with training in this area which assists in protecting the health and welfare of individuals. The environment has been improved with a number of areas being redecorated, new carpeting in house one and a new kitchen in house two. What the care home could do better: To assist in safeguarding people a full employment record with explanations for any gaps must be in place for each member of staff. All staff need to receive regular training on safeguarding people. The record of staff training needs to be kept up to date to make sure that staff receive updates when required. Staffing levels, particularly in house four, need to be kept under review. Consideration should be given to providing information on the service in more accessible formats. Staff should keep more detailed daily notes which set out the care or support provided in more detail. This will assist in ensuring that individuals receive the right type and levels of support. The kitchen in house one is in need of up dating. CARE HOME ADULTS 18-65 Coombe Oak Warren Road Kingston Upon Thames Surrey KT2 7HY Lead Inspector Liz O`Reilly Unannounced Inspection 21st October 2008 10:00 Coombe Oak DS0000013382.V372898.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 Oak DS0000013382.V372898.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 Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe Oak Address Warren Road Kingston Upon Thames Surrey KT2 7HY 020 8547 3237 0208 974 5801 chris.stringer@welmede.org.uk 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) Welmede Housing Association Ltd Julie Anne Webb Mandy Williams Sharon Joanne McLaughlin Care Home 22 Category(ies) of Learning disability over 65 years of age (22) registration, with number of places Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Room 2, House 3 may be provided with a suitable alternative floor covering in place of carpet. To be reviewed at least annually. 15th May 2007 Date of last inspection Brief Description of the Service: Coombe Oak is a residential care home providing care for twenty service users with learning disabilities. Care is provided in four separate houses on one site. Each house provides ground floor accommodation for service users. The Royal Borough of Kingston upon Thames own the home and it is managed by Welmede Housing Association Limited on a contract basis. Information about the service is available in the Statement of Purpose and Service User Guide. The current range of charges is £1200 to £1700 per week. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means people who use this service experience good quality outcomes. This unannounced inspection was carried out by two regulation inspectors and included a visit to the service, discussion with people who use the service, staff and managers. Surveys were provided for a sample of staff and individuals who use the service. We received nine completed surveys from people who use the service and three from staff. The manager carried out their own assessment of the service (AQAA) for the CSCI. Information received from all of the above sources along with our observations have been used to reach the judgements made in this report. What the service does well: People who use the service told us “I like living here”, “I like my room, I have everything I need” and “I think the staff are great”, “they help me” and “they are good cooks here”. No one who uses the service made negative comments about the service or staff either directly to us or through the surveys we provided. We observed very good levels of communication between staff and people who use the service. Individuals told us that they felt staff listened to them and acted on what they said. Staff were observed to respect the privacy and dignity of individuals throughout this inspection. Staff keep the needs of individuals under review and adjust the levels of support for individuals as needed. Where anyone expresses a wish to move to more independent living this is taken seriously by staff and action is taken to investigate how this can be achieved. People who use the service are encouraged to follow their own interests and offered opportunities to try new things. The range of activities available is good. Throughout this inspection we saw staff offering informed choice to people who use the service in all aspects of daily living. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coombe Oak DS0000013382.V372898.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 Oak DS0000013382.V372898.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 & 4 People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Good information is available to people about the service they can expect from each house. Assessments are completed before people move in to make sure that the home can meet their needs. EVIDENCE: People who use the service told us, “I do like it here, in general it is quite good”, “I like living here better than where I used to live” and “it’s better here because there are no stairs”. Individuals also told us they visited “quite a few times” before they moved in. One person told us they decided to move in because “I liked Coombe Oak when I came to visit” and another person said “I visited a few times and stayed overnight before I moved in”. From the surveys, seven people told us they were asked if they wanted to move into the home. Four people felt they had enough information to make a decision about moving in. Three people were not sure and one person could not remember. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 9 Leaflets are available which give information about each of the houses which make up the service. Details of who the service is available to, the organisation, staff, leisure activities and the complaints process are included. Consideration could be given to making this information available in more accessible ways. Before anyone moves in a series of assessments are carried out. These assessments by the local authority and staff from the home help to make sure that Coombe Oak is the right place for the person and that their needs can be met. The assessments also ensure that staff have some understanding of the needs and wishes of individuals from day one of their stay. Coombe Oak DS0000013382.V372898.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 this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use the service are involved in developing and planning their care and. Staff place a high priority on supporting people to take control of their own lives. Individuals are supported to make their own choices and decisions. Risk assessments are carried out. EVIDENCE: People we spoke to knew they had a care plan and told us they were involved in producing and reviewing the plan. Care plans are person centred and include good information covering all areas of the individuals life, support needed, likes and dislikes, ‘things I’m good at’ and ‘things I don’t like’, feelings, weekly plan of outings and activities, dreams and risk assessments. Two of the plans we looked at were being updated to include more photographs. Case files include individuals religious preference and whether they are practicing and need support or assistance to attend church or services. One person told us they “go to church every week” and “I enjoy going to church”. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 11 We saw individuals achievements for 2007, this is a good record of what individuals have done throughout the year and how far they have progressed in meeting their personal goals. Staff have included the needs and wishes of individuals in relation to sexuality and relationships as part of the care planning which allows people to talk about their feelings and for staff to support them in these aspects of their lives. Staff were seen to offer support and care in line with the instructions and wishes of individuals as recorded in care plans. Throughout our visit we heard staff offering choices on all aspects of daily life. People told us, “I decide what I do”, “I pick where I go when I go out”, “I choose what I wear and what jewellery I want”. Through the surveys seven people who use the service told us they ‘always’ make their own decisions about what they do each day and that they ‘always’ did what they wanted. One person felt they ‘sometimes’ decided what they would do. Individual risk assessments are in place which assist in supporting people with doing the things they enjoy in a safe and considered manner. Staff told us they are ‘always’ provided with up to date information on the needs of the people they support. Information provided through the self assessments form indicated that the needs of each individual are regularly assessed. If individuals feel they would like to move on, either to more independent living, or with another group of people, this is taken seriously by the staff group. Arrangements are being made to support one person we spoke to to move to more independent accommodation. This person was pleased that action was being taken and was “looking forward” to being more independent. For another person who has expressed a wish to move staff are arranging for them to be provided with an advocate to assist them. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 12 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 this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to take part in a variety of activities in the home and the local community. People have the opportunity to maintain important family relationships. People who live there enjoy the food provided. EVIDENCE: Staff told us that since people who use the service no longer attend day centres for full days more opportunities have emerged for the development of individualised activities in the community. People we spoke to had been taking part in a variety of activities that day including , cycling, attending college, shopping, out to the pub and attending a club. Individuals told us “I like going to the bus and Waterloo” and “I have an Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 13 Oyster Card”. People told us that they fill our their activities board and if they struggle for ideas staff will offer suggestions. Individuals told us that that they choose which staff members they do activities with and one person told us they often change their mind on the day, so do something else. When asked about activities people told us through surveys that; ‘I like going shopping’, ‘I don’t like to be rushed or go anywhere early’, ‘It depends how I’m feeling’. Individuals said, ‘Kingston’, ‘party’, ‘beer’, ‘church’, ‘hamburger’ and ‘Saturday is take away day and I like fish and chips’ The organisation employs their own staff to support people with activities. The organisation has its own Allotment where people can grow their own vegetables. One person who uses the service has taken part in a fishing trip. Individuals enjoy drama, cooking, bowling, rambling, line dancing, bingo and art clubs. Staff support individuals to maintain family and personal relationships. People who use the service told us that they could have visitors and could meet with them in private if they wanted to. One person told us via the survey that they had spent a few days at their family home as part of their birthday celebrations. People are offered a varied menu to meet their cultural, religious and medical needs. We also saw people have alternative meals when the food served is something they don’t like. We received mixed comments about the food including; ‘it’s not very good here’; ‘I prefer to eat out’; ‘the food is good’; ‘I enjoyed lunch’. However the majority of comments received were positive. People told us the staff were “good cooks”. We observed staff supporting people who needed assistance with eating in a considerate and respectful manner. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 14 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 this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use the service receive appropriate personal and healthcare support. Individuals are supported to access community and specialist healthcare facilities as required. Medication is well managed. EVIDENCE: Good information is available on the health care needs of individuals. Staff support people to keep health care appointments and will act as advocates to access health care services. Where an individual requires significant personal and health care support we found staff taking great care to follow the advice and guidance provided by other health care professionals. We saw good recording of how the needs of individuals are to be met by staff. Daily recording was less detailed and did not always provide information on actions taken. Consideration should be given to staff providing more detail of the actual care provided in the daily Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 15 recording. This will assist in ensuring that, where individuals have more complex needs, all the support required is given. Staff were seen to communicate in a gentle tactile manner with one person with high personal and health care needs. Staff were observed to take care in protecting the privacy and dignity of individuals. We looked at a sample of the medication. We found medication to be well managed and safely stored. Good systems were in place for checking and recording all medication. Staff are also supplied with clear guidance on the administration of medication to be given when required. Staff told us that all staff who administer medication have completed medication training. People told us ‘staff look after my medication’ and ‘staff give me medication when I need it’. People felt safe with staff managing their medication. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 16 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 this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure, which is available for people who use the service and their representatives. People are aware of how to make a complaint. Policies for safeguarding people are in place. EVIDENCE: We asked people who use the service, through the survey, if they knew who to speak to if they were not happy and if they knew how to make a complaint. All of those who responded to the question knew how to make a complaint. One person told us they had ‘no complaints but would speak to the manager’ if they did. Individuals told us that they would speak to ‘my keyworker’, ‘the manager’ and ‘my advocate’ if they were unhappy about something. Individuals we spoke to during this visit also knew who they would speak to if they needed to complain. All of those who responded to the staff survey were confident they knew what to do if concerns were raised with them. One member of staff told us that all staff are asked to read and sign that they understand the complaints procedure. Information on how to make a complaint was seen to be on display in the houses in a written and pictorial format. The information on display included Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 17 some examples of what people have complained about and what will happen should anyone make a complaint. How to make a complaint is also discussed at tenants meetings. Staff informed us that they have received training on safeguarding individuals. However records showed that some staff last had this training in 2006. The manager should ensure that all staff receive regular refresher training on safeguarding people. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 18 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, 25, 26 & 30 People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Each house provides a comfortable environment for people who use the service. The buildings are well maintained, clean and fresh. EVIDENCE: All four houses provide similar accommodation and each house has its own garden. We found generally the service was well maintained. New carpeting has been laid in house 1 and house 2 has a new kitchen. House 1 is in need of a new kitchen. We found broken drawers in this kitchen, handles missing and a gap between the cooker and the work surface which could pose a hazard. People who use the service told us they liked their rooms. We saw that individuals had been consulted on the décor in their room. One person told us Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 19 that they had ‘just had new carpet’ in their room. Another person showed us the aids and adaptations which they had so that they could operate their equipment themselves. All areas of the service we saw were clean and fresh. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 20 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, 33, 34, 35 & 36 People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use the service are happy with the way staff support them. Staff are provided with good opportunities for training and appropriate checks are carried out on staff before they start work in the service. Generally sufficient staff are available to meet the needs of individuals. However additional staffing should be provided in one house to ensure levels of support are maintained. EVIDENCE: People who use the service told us “I like the staff here” and “they are very good”. Seven people who responded to surveys said that staff ‘always’ listened to them and acted on what they said. One person did feel that staff were sometimes ‘to busy’. Staff told us they had good opportunities for training. Staff felt the training they received was relevant to their role and that refresher training assisted in keeping them up to date with current good practice. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 21 Staff have taken part in a wide variety of training over the last twelve months including, medication, safeguarding, first aid, fire safety, moving and handling. Seventy percent of the permanent staff employed in the service have achieved or are working towards NVQ level 2 or above. One house manager spoken to is in the process of completing NVQ level 3. The record of training we saw indicated that some staff had not received training in medication or safeguarding people for some years. The record of training for each person should be kept up to date so that refresher training can be provided. Individuals told us they had received induction training when they first started work. One person stated that as they were new to support work this induction was very helpful. All staff agreed checks were carried out before they started work including Criminal Records Bureau checks and taking up references. We looked at a sample of staff files and found records of induction training and pre employment checks. Staff are requested to fill in an application form before they are interviewed. We found instances where the dates supplied on the record of employment did not show a clear continuous history. Managers need to make sure that a full employment history with start and end dates for each employment are recorded. A record of the reasons for any gaps in employment should be kept on file. These checks will further safeguard people who use this service. Discussion with staff and people who use the service indicated that sufficient staff are available to meet the needs of individuals. Senior staff informed us that staffing levels are reviewed on a regular basis. We are aware that the organisation are seeking further funding for additional staff in one house. Discussions with staff in this house and people who live there indicated that there was pressure on staff in this unit. People who live in this unit did tell us that staff were “very busy” and “work hard”. Staff expressed concerns that the increased pressure may be being felt by people who live in the unit. That individuals may be feeling they were not receiving the amount of staff time and attention they were used to. The organisation needs to keep staffing levels under review. Staff told us they felt well supported by the management. Regular staff meetings are held and staff receive individual one to one supervision from a more senior member of staff. This ensures that staff are supported and managers can ensure that individuals are working in line with the stated aims and objectives of the service. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 22 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 this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use this service feel that they are listened to. The service is well managed. Staff carry out regular checks on the building and equipment to ensure the safety of people who use the service, staff and visitors. EVIDENCE: The service is run by a management team. Each house has its own manager, with the area manager having overall responsibility for the service. At the time of this inspection the service was working towards achieving a separate registration for each house. The managers have completed the registration Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 23 process and an application for separate registration of the buildings was to be made. Quality assurance and monitoring includes listening to what people who use the service say through regular meetings. Surveys are sent out to families and regular visitors. The organisation is looking to improve their surveys and consultation with people who use the service over the next twelve months. The organisation carry out their own regular checks on the service and produce an annual development plan. We looked at a sample of the record of health and safety checks carried out. These records were well maintained and showed regular checks of the fire alarm system, electrical appliances and water systems. Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 24 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13(6) Requirement To further protect residents from abuse all staff must receive training in the Protection of Vulnerable Adults every year. Timescale of 01/11/07 not met. To assist in safeguarding people who use the service a full employment history together with a satisfactory written explanation of any gaps in employment must be available for all staff. Timescale for action 01/02/09 2. YA34 19 Schedule 2 (6) 01/02/09 Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 26 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. 5. Refer to Standard YA1 YA18 YA24 YA33 YA35 Good Practice Recommendations Consideration should be given to producing information on the service in a variety of formats to aid access. To ensure that individuals are receiving the care or support they need staff should make more detailed records of the care or support they have provided. Consideration should be given to up dating the kitchen in House 1. To ensure that people who use the service receive the levels of care and support they require staffing levels, particularly in House 4, should be kept under review. To make sure that people who use the service are supported by a well trained staff group the record of staff training needs to be kept up to date and staff should be provided with regular up dated training Coombe Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Oak DS0000013382.V372898.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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