Care Home: Cotswold

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What the care home does well The interaction observed between staff and residents was appropriate, even when dealing with some emotional difficulties staff showed a calm and measured approach. They responded well to the needs of the residents and they were extremely polite when addressing them. Residents also responded well to staff`s request. Good assessments are carried out before people are admitted to the home. Health care needs are met and visitors are made welcome. Staff are helpful and caring towards the residents. Cotswold home provides residents with a good standard of care in a comfortable environment. Activities to suit the taste and preference of residents are facilitated and this maintains a good level of stimulation. The privacy and dignity of residents is upheld. The staff members on duty were positive about different aspects of their work. All staff members complete in depth training when they first start working at the home. This gives them information and knowledge about safe working practices and specifically about people with autistic spectrum disorders. They are also able to properly look after and respect residents` culture and religious beliefs.Staff members spoken to said they are well supported. NVQ training for staff is being given a high profile. Evidence available shows that staff receive regular supervision. What has improved since the last inspection? All six requirements made following the previous inspection in December 2007 are being implemented to good effect. Residents` contracts are in place and have been updated to include the signature of their representatives. This is to ensure the rights of people living at the home are being upheld. A new care plan is being introduced, which ensures that goals are broken down into measurable tasks with specific timescales for implementation. This ensures that residents have their individual needs and aspirations addressed satisfactorily. Referrals are now appropriately made, following the local safeguarding protocols. This ensures that residents are appropriately protected and their well being, promoted. The practice of locking the office door by some staff members has been risk assessed and action taken as appropriate. Redecoration and changes to the environment are being made so that the people living at the home have a pleasant and homely environment in which to live. A more robust approach to recruitment has been adopted both in terms of the detail of information required and the need to follow up if the information provided is not satisfactory or gives cause for concern. The new manager has been in post since September 2007. In the short time that she has been in post the manager has implemented a number of care and staff management systems to good effect. Evidence available shows that the quality of care and support for residents has improved and the home is being well managed. What the care home could do better: There are three requirements arising from this inspection report; these must be addressed. Complete and accurate records must be kept of all medication administered. This would demonstrate that residents receive the medicines prescribed for them. The remaining upgrading programme of redecoration including the sanitary facilities must be completed.Records of fire drills must include the names of participants, evacuation timescales and remedial action taken, if any. CARE HOME ADULTS 18-65 Cotswold Graze Hill Ravensden Bedfordshire MK44 2TF Lead Inspector Mr Neil Fernando Unannounced Inspection 22nd May 2008 10:45 Cotswold DS0000014891.V364984.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 Cotswold DS0000014891.V364984.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. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotswold Address Graze Hill Ravensden Bedfordshire MK44 2TF 01234 772196 01234 772194 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) The Disabilities Trust Christine Why Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must complete an NVQ 4 in care by 31 December 2006 Date of last inspection 13th December 2007 Brief Description of the Service: Cotswold is registered to provide care for up to five adults with a learning disability. Residents have an autistic spectrum disorder and associated challenging behaviour. This is one of many homes owned and managed by The Disabilities Trust who is a national provider. The accommodation is situated on the edge of Ravensden village just outside Bedford town. The building has been adapted and is of a domestic style. The ground floor offers an office, a large open plan lounge and dining area, a kitchen, a laundry room, one bedroom, a toilet and a bathroom with toilet facility. The first floor consists of four bedrooms of varying size, a bathroom and a separate toilet. There is a large enclosed garden to the rear, with vegetables and flowers grown by residents. To the side there is a large double garage, with an enclosed space that could be used for activities. The home is in a secluded location with surrounding gardens. Two cars belonging to the home enable easy access to various community facilities. The public transport service is limited to Ravensden; there is adequate parking available at the home. A copy of the service user’s guide and inspection report is available for anyone to read. The basic monthly fee is £1789.53 per week. There could be additions to this depending on the care needs of the individual person. Cotswold DS0000014891.V364984.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 the people who use this service experience good quality outcomes. We, the Commission for Social Care Inspection, undertook this unannounced key inspection on 22 May 2008. We spoke with the manager and 3 staff. We had a look round the accommodation and viewed a range of records the home must keep. We could not seek the views of the residents given their learning and verbal communication difficulties. However, we spent a significant amount of time discretely observing residents and staff care practices. At the time of the visit, there were 4 residents accommodated with 1 vacancy. We received a completed “AQAA” (Annual Quality Assurance Assessment) – a document, which gives the manager the opportunity to tell us how the agency is meeting the standards and regulations. Surveys to seek the views of relatives and staff have been sent and any information received would be included in this or next inspection report, as appropriate. The manager was present throughout the inspection. What the service does well: The interaction observed between staff and residents was appropriate, even when dealing with some emotional difficulties staff showed a calm and measured approach. They responded well to the needs of the residents and they were extremely polite when addressing them. Residents also responded well to staff’s request. Good assessments are carried out before people are admitted to the home. Health care needs are met and visitors are made welcome. Staff are helpful and caring towards the residents. Cotswold home provides residents with a good standard of care in a comfortable environment. Activities to suit the taste and preference of residents are facilitated and this maintains a good level of stimulation. The privacy and dignity of residents is upheld. The staff members on duty were positive about different aspects of their work. All staff members complete in depth training when they first start working at the home. This gives them information and knowledge about safe working practices and specifically about people with autistic spectrum disorders. They are also able to properly look after and respect residents’ culture and religious beliefs. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 6 Staff members spoken to said they are well supported. NVQ training for staff is being given a high profile. Evidence available shows that staff receive regular supervision. What has improved since the last inspection? What they could do better: There are three requirements arising from this inspection report; these must be addressed. Complete and accurate records must be kept of all medication administered. This would demonstrate that residents receive the medicines prescribed for them. The remaining upgrading programme of redecoration including the sanitary facilities must be completed. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 7 Records of fire drills must include the names of participants, evacuation timescales and remedial action taken, if any. 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. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 8 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 Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 9 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): Standard 1, 2, 4 and 5 Quality in this outcome area is good. The home makes sure it can meet people’s needs by getting detailed information about them before they are offered a place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user’s guide have been recently reviewed and updated by the manager. The AQAA indicates All prospective service users have a full individual assessment completed by the Disabilities Trust’s Clinical Psychologist before a placement is identified. The needs of the service users are taken into account before a placement is agreed or offered. Transitionary visits are planned, taking into account the individual needs. All assessments are person centred to meet the individual’s needs and aspirations. All of the four residents have lived at Cotswold home for a number of years; indeed, there have been no new admission to the home in the last couple of years. Care files for two people show that when the home receives a new referal, a detailed assessment of needs is completed involving the manager, Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 10 potential resident, family, the Trust’s clinical psychologist and and other important people. We learn from the manager and staff members that the prospective resident and their family have the opportunity to visit the home for a cup of tea, a meal or over night stays until a decision could be made about whether they could live at the home or not. This is because the communication difficulties and challenging behaviours experienced by people who live at this home could sometimes mean that even if individual needs could be met, this would not be in the best interest of residents already living at this home. Staff said that they would help the prospective resident decide if the home is suitable for them. Overall, evidence shows that the home is careful to only offer a place to the resident whose needs and aspirations it can meet. Individual contracts are in place and have been updated to include the signature of the residents’ representatives. This is to ensure the rights of people living at the home are being upheld. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 11 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): Standards 6, 7 and 9 Quality in this outcome area is good. Detailed care plans with achievable targets are being introduced; thus ensuring that identified needs are addressed and residents receive the necessary care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The resident’s care plan is drawn up from a range of assessment of needs including care manager’s reports, input from family, the Trust’s clinical psychologist, staff’s on going assessment and contributions from any other professionals. The manager said that a new care plan is being introduced to reflect more comprehensively the needs of each resident. The care plans for two people using the service were viewed; each person has a very detailed person centred care plan, which identifies how their individual needs would be met. The Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 12 information had been kept up to date and reflected the support being provided. “We always follow what has been included in the care plan of the resident”, said one staff member. On the day of the inspection, we met two psychologists from the Trust who were assisting the manager to update a resident’s care plan, in order to reflect their identified needs. Records show that each resident has their care plan reviewed six monthly. Residents also have an annual review each, which are undertaken by the care manager from the placing authority. The care plans and minutes of reviews seen, indicate that staff seek to involve the residents and their representatives in all aspects of their care; for example, staff have obtained the signature of the resident’s representative in the care plan where appropriate, which demonstrates their participation. There is evidence that individuals are involved and given support to understand the reason specific risk reduction strategies are used to promote their safety and wellbeing. Risk assessments have been completed for all residents and these are updated as necessary. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. A range of social and recreational activities is being facilitated. This assists in the development and maintains a good level of stimulation for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA indicates All service users have a plan of activities outside of the house which they are encouraged to follow. All service users are encouraged and enabled to go swimming to the local swimming pool at least weekly. Service users are enabled to access local college for courses ranging from computers to horticulture. The care records viewed show that the services available reflect the needs of each individual in relation to their interests, abilities and age. Where individuals have identified through one to one discussion with staff that they Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 14 want different things to do, the care records indicate the action being taken to address this. Individual needs associated with culture and diversity are being identified through assessments, reviews and staff’s communication with residents. All residents have had an assessment carried out by a clinical psychologist and speech and language therapists with respect to their individual needs, focussing on communication and activities, in particular. A set plan of activities is in place and this is reviewed and adapted at each house meeting. Everyone takes part in their own choice of activities, either individually or in groups. These include swimming, shopping, cycling, visiting families, train rides, local events, visits to the local pubs, eating out, clubs and entertainment venues. Two cars belonging to the home enable easy access to various community facilities. Individuals follow their own routines when they are at home including being involved in household tasks and gardening. Social contact with family and friends is encouraged. Staff members and other residents only enter rooms when invited. Residents are able to spend time alone if they wish or in the company of other residents and staff. Staff members respect residents’ right to live as they like in their own space. Residents’ rooms were seen and these were neat and tidy. Menus are planned with the residents and information is available to assist them make decisions. Consideration is given to individual nutritional needs so that residents have access to healthy options. Mealtimes are now very much a social occasion. Residents are encouraged to eat at the table together with staff. We observed residents and staff members having their lunch together. Mealtime was relaxed, unrushed and an enjoyable social occasion for all. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 15 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): Standard 18,19 and 20 Quality in this outcome area is good. Procedures followed by staff ensure that residents receive good quality personal and healthcare support and they treat residents with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The way in which personal care should be provided is recorded in the care plans. This information is shared with the care staff to ensure that residents have continuity of care and so that care is provided in a manner familiar to them. People living at this home have a range of physical needs, as well as communication difficulties. The care plans have been reviewed on a regular basis and amended as necessary. Detailed recording of each person’s personal and health care is maintained on each shift. Entries made had been dated but minor improvement is needed to ensure that the name and signature of the Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 16 staff member making the entry is included at all times. The manager has agreed to take action to address this inconsistency. All residents are registered with local GP services. Other people the residents have access to include local health professionals as well as dentist and optician. The AQAA indicates, All staff responsible for administering medication have certified training. All medication storage and administration is recorded on individual MAR sheets. Appointments for consultant psychiatrist are arranged 3 monthly. Service users attend clinics at Twinwoods Clinical Resource Centre for people with Learning difficulties for a variety of health care needs including sensory impairments, bowel clinics, behavioural support. The home has a written policy on medication; three staff including a senior member confirmed they have received training on this subject. The medication cupboard is located in the staff office with the keys being held at all times by a member of staff. Records are kept when medication is administered to residents. However, there were a few occasions when the medication administration records (MAR) sheets had not been signed. Complete and accurate records must be kept of all medication administered, in order to demonstrate that residents receive the medicines prescribed for them. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 17 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): Standards 22 and 23 Quality in this outcome area is good. The policies and procedures on complaints and adult protection protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place, which states that all complaints are responded to within 28 days. The manager said that all staff have received training on the management of complaints. Staff interviewed demonstrated a good understanding of the procedure and who to report any concerns to. “I know what to do if I receive a complaint”, said a staff member. Staff spoken with said that given the learning disability of the current residents, it is more appropriate to frequently informed the residents about the complaints procedure and how to raise any concerns they may have about the service. The home maintains a complaints record. There have been no recorded complaints since the last inspection carried out in December 2007. There have been no complaints made to the Commission during this period. The home has adequate policies concerning adult protection and whistle blowing. All staff have received training in safeguarding adults; the staff spoken with were aware of the procedures for reporting any concerns or events, which may affect the safety or welfare of any person living at Cotswold Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 18 home. Since the last inspection there has been one safeguarding incident. The matter was appropriately referred to the social services adult protection team. The staff team under the leadership of the manager dealt with the safety and protection issues appropriately. Cotswold DS0000014891.V364984.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): Standards 24, 25 and 30 Quality in this outcome area is good. Although Cotswold home offers its residents a clean and safe environment, some redecoration work is required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA indicates Began replacing flooring to improve environment. Finances to redecorate communal areas of the house agreed. Redecoration of the lounge to begin early January. Service users encouraged to take part in gardening, planting, and weeding. Cotswold home is spacious and airy, with all single bedrooms offered to its residents. All bedrooms seen are personalised to an extent to reflect the tastes and interests of the occupants, with gadgets, pictures and hobby materials. People accommodated are also involved in choosing furniture and redecoration Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 20 for their room. There are some homely touches with photographs and ornaments that residents have chosen to have around the house. Furniture and fittings in all areas viewed including the dining room and lounge are of a domestic type and of good quality. The standard of decoration in the upgraded parts of the accommodation including the dining room and lounge is good. However, the remaining parts of the building including the sanitary facilities require redecorating. A good standard of cleanliness was evident throughout those areas viewed. There were no offensive odours present. The laundry facility is suitable and adequate for the people in residence. There are infection control policies and procedures in place. There is a large enclosed garden to the rear of the property with mature trees and vegetables, and flowers grown by residents. To the side there is a large double garage, with an enclosed space that could be used for activities. Cotswold DS0000014891.V364984.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): Standards 32, 33, 34, 35 and 36 Quality in this outcome area is good. The recruitment process is robust and staff have access to appropriate training and supervision. This means that residents can be confident of being in safe hands and looked after by a skilled staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA indicates, The majority of the staff team have been employed for a considerable length of time ensuring relative continuity for the individual service users. All the staff have a full understanding of each individuals needs. Staff receive training relevant to the service users needs living at Cotswold. The duty rota for a period of one month showed that there are 4 staff available in the morning and 3, in the afternoon shifts. There are 2 waking members available on night duty. Staff spoken to said that “there is good staff cover at all times and the manager is available on call, if required”. Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 22 In terms of skill mix, the staffing arrangements are appropriate to ensure that the needs of the people accommodated could be met. Staff receive induction that covers mandatory health and safety training. Records and information from staff show that a “good level of training is being provided on a wide range of subjects”. The personnel recruitment files for 3 staff including the last member who joined the team were scrutinised. They provided evidence that various checks including Criminal Records Bureau checks and references had been undertaken as required by The Care Homes Regulations 2001. 10 of the 16 care staff hold an NVQ level 2 or equivalent in care, 1 is currently working towards it and a further 3 are scheduled to start the course in Autumn 2008. This means that the home has already achieved a ratio of 62.5 of staff with NVQ Level 2 or equivalent. Staff meetings are held monthly and staff have good opportunity to raise any issues. Evidence shows that all staff now receive regular supervision. “I am very happy with my supervision”, said two staff members. Cotswold DS0000014891.V364984.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): Standards 37, 38, 39, 41 and 42. Quality in this outcome area is good. The staff team are being supported and managed well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager has been in post since September 2007; her application to become the registered manager was approved by the Commission in February 2008. In the short time that she has been in post, the management of this home has improved. Evidently, this has been due to the effort, hard work and commitment of the registered manager and the staff team. The staff members are working well as a team, and morale is good. The manager works closely Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 24 with the residents and staff team. Staff also reported that, “Good management support is available”. Monthly visits by a designated person to ensure appropriate standards are being maintained have been carried out; reports on the visits carried out are available at the home. There is no formal quality monitoring system to seek the views of residents and other stakeholders regarding the quality of service offered at this home. The manager was fully aware of this shortfall and she was in the process of introducing a system (form of annual surveys), based on seeking the views of residents, relatives and other stakeholders, in order to improve the quality of its service for residents. The manager was also aware that the results of surveys should be published and made available to residents, representatives and other stakeholders including the Commission. A requirement is therefore not made given that arrangements are in hand for the manager to address this issue. Positive interaction between residents and staff was observed during the visit. Staff were on hand to assist where required but also felt able to give residents the opportunity to follow their own routines and preferences. Staff members treated residents very well. We looked at some of the records the home is required to keep; these were found to be order. Health and safety matters are being attended to; however, the fire drills record must include timescales for evacuation, name of participants and remedial action taken, if any. Cotswold DS0000014891.V364984.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 3 2 3 3 X 4 3 5 3 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 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X 3 2 X Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) 17 (1) (a) Requirement Complete and accurate records must be kept of all medication administered, in order to demonstrate that residents receive the medicines prescribed for them. The remaining upgrading programme of redecoration including the sanitary facilities must be completed. Records of fire drills must include the names of participants, evacuation timescales and remedial action taken, if any. Timescale for action 22/06/08 2 YA24 23 (2) (d) 30/09/08 3 YA42 17 (2) Sch. 4 14. 15/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 27 Cotswold DS0000014891.V364984.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cotswold DS0000014891.V364984.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. 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