Care Home: Cotswold Cottage

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What the care home does well People using the service are thoroughly assessed prior to admission and are given opportunity to visit the home beforehand to ensure it meets their needs. People using the service have a varied and active lifestyle which reflects their interests, provides them with nourishing meals and offers them opportunity to try new experiences and have contact with family, friends and the community. The health and personal care needs of people living at the home are well met, promoting health and well-being and ensuring that they receive medication in a safe and consistent manner. Complaints and adult protection are effectively managed to listen to views of people who live at the home and reducing the risk of harm to them. The home is clean, well decorated and adequately maintained, promoting a positive environment for the people who live there.The home provides staff cover to meet needs and undertakes thorough recruitment procedures, coupled with effective training to ensure staff have the right skills and competencies to support the people who live there. The management and administration of the home promote continuity and quality of care for the people who live there and ensure that risk is safely managed to reduce the likelihood of injury or harm. What has improved since the last inspection? No requirements were made at the previous inspection. What the care home could do better: Five recommendations have been made as a result of this inspection: Evidence of regular reviewing of information on care plan files, and changes where necessary, is needed to show that documentation is still current to people`s care needs. The date of assessment and who undertook it needs to be noted on the pressure risk indicator evaluations (Waterlow) so that it is clear to see when these were produced and by whom. Individual protocols on the use of rectal diazepam need to be re-issued by the doctor or specialist in order that they are up-to-date and dated. All reports of visits undertaken by the provider should be forwarded to the home, to show that monitoring has taken place monthly. Policies and procedures containing the contact details of the Commission for Social Care Inspection need to be updated to include the new regional address in Maidstone, Kent, so that staff and the public have the correct details to hand. CARE HOME ADULTS 18-65 Cotswold Cottage Grange Road Hazlemere High Wycombe Bucks HP15 7QZ Lead Inspector Chris Schwarz Key Unannounced Inspection 18th February 2008 11:20 Cotswold Cottage DS0000022965.V359275.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 Cottage DS0000022965.V359275.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 Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotswold Cottage Address Grange Road Hazlemere High Wycombe Bucks HP15 7QZ 01494 527642 01494 527642 manager.cotswold@fremantletrust.org admin@fremantletrust.org The Fremantle Trust 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) Diane Bryant Care Home 8 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2006 Brief Description of the Service: Cotswold Cottage is a detached property located at the end of a quiet residential road in Hazlemere, High Wycombe. The home is run by The Fremantle Trust and is registered to provide accommodation for up to eight people with learning and physical disabilities. The home is near to local shops and public transport links into High Wycombe and Amersham. Cotswold Cottage has eight single bedrooms, some on the ground floor, and two lounge areas. There is a large kitchen/dining area and sufficient bathrooms and toilets. The home has an enclosed garden and overlooks farmland to the rear. Each person living at the home has considerable care needs and the home has appropriate aids and adaptations to assist with daily living tasks. People living at the service were paying £255.80 in maintenance fees per week. Cotswold Cottage DS0000022965.V359275.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 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was conducted over the course of a day and covered all of the key National Minimum Standards for younger adults. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion and comment cards were sent to staff, relatives and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussion with the manager and other staff, opportunities to meet with people using the service, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and people who use the service are thanked for their cooperation and hospitality during this unannounced visit. What the service does well: People using the service are thoroughly assessed prior to admission and are given opportunity to visit the home beforehand to ensure it meets their needs. People using the service have a varied and active lifestyle which reflects their interests, provides them with nourishing meals and offers them opportunity to try new experiences and have contact with family, friends and the community. The health and personal care needs of people living at the home are well met, promoting health and well-being and ensuring that they receive medication in a safe and consistent manner. Complaints and adult protection are effectively managed to listen to views of people who live at the home and reducing the risk of harm to them. The home is clean, well decorated and adequately maintained, promoting a positive environment for the people who live there. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 6 The home provides staff cover to meet needs and undertakes thorough recruitment procedures, coupled with effective training to ensure staff have the right skills and competencies to support the people who live there. The management and administration of the home promote continuity and quality of care for the people who live there and ensure that risk is safely managed to reduce the likelihood of injury or harm. 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. Cotswold Cottage DS0000022965.V359275.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 Cotswold Cottage DS0000022965.V359275.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): 2 Quality in this outcome area is good. People using the service are thoroughly assessed prior to admission and are given opportunity to visit the home beforehand to ensure it meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had not been any new admissions to the service in the past twelve months. At the previous inspection in 2006, the process of admission for the most recently admitted person was discussed and documents relating to assessment of care needs were read and found to be in good order. The written admissions procedure was looked at on this occasion and describes a detailed process, outlining responsibilities of the registered manager. Information was also available about the service in a statement of purpose and service users guide. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. There is good regard for the diverse needs of the people living at the home and their requirements related to their disabilities, lifestyle choices and personal preferences are sought, recorded and met by the staff team, respecting their rights, choices and individuality. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were in place for each person living at the service and needs had been recorded using a corporate format. An ‘essential information’ sheet recorded details such as date of birth, preferred form of address, next of kin, doctor, care manager, any aids or equipment required to assist with daily living and essential health information. People’s preferred daily routine was noted alongside their likes and dislikes. Support plans were in place covering areas such as health care needs, how people communicate, personal care requirements, family and social contacts and lifestyle. All documents had been dated and signed. Reviewing of needs was taking place but care plan files did not consistently show this to be the case. In some parts of the files looked at it was clear to see that information had been reviewed, as date of production was recent, but in some areas where the element of the support plan had been produced a while Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 10 ago it was not clear that staff had reviewed the information whether there were changes or not. Care plan review sheets at the front of each file had not always been used to best effect, in one case for each month for over a year someone had written “being updated” without further detail. Likewise, some of the risk assessments to support people with daily living appeared out of date and relevance to current practice was not readily apparent because the front sheet did not provide the necessary information. A separate file containing review meeting notes provided broad evidence that needs were being looked at periodically, and where there was change in people’s circumstances, but this record was secondary to the care plans. It is recommended that the way in which care plans are evaluated is improved to clearly show that the information recorded is still current and reflective of care needs and that no change to circumstances is also made clear. People’s money was being managed as part of the provider’s residents’ savings scheme with service user expenditure being claimed back via an Imprest system. The home’s administrator and manager undertake regular checks of the system and receipts were being kept to verify spending. There was a managing service users’ money procedure to refer to in the operations manual. People were being supported to make decisions where they were able to and to participate in planning menus. Consultation takes place with families where people are unable to make informed choices. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. People using the service have a varied and active lifestyle which reflects their interests, provides them with nourishing meals and offers them opportunity to try new experiences and have contact with family, friends and the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Daily reports and review notes showed that people using the service are involved in different activities and make use of the local community resources. Trips to London, going to the pantomime, meals out, visiting a local model village, a day trip on a canal boat, walking and horse riding had been enjoyed by service users and they had been supported by staff to go shopping for any personal items such as toiletries and clothes. All of the service users attend day services for part of the week. Holidays had been booked for two people to go to The Canaries and some other service users were going to the Isle of Wight. A party had been held at the home at the weekend to celebrate one person’s birthday and service users were going out to the Rainbow Club in the evening on the day of this visit. Use Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 12 was being made of free public transport for those people who can access buses and adapted taxis for people using wheelchairs. Contact between people using the service and their family and friends was being supported by staff. No restrictions were being placed upon visiting. One relative said that home helped keep in touch and added “Cotswold Cottage staff contact me directly to give me their views/inputs on my son’s needs.” Regimes within the home were flexible. People were able to move around the home and spend time in their rooms if they wished, staff used preferred forms of address and interacted with service users. Any personal care was carried out discretely and in private. Meals and mealtimes were well managed at the home. Staff were serving largely homemade meals, such as leek and potato soup on the day of the inspection, and incorporating lots of salad, vegetables and fruit into people’s diets. A useful folder in the kitchen contained information on each person’s needs at meal times, such as the assistance and adaptations they require, plus the regimes for those people who have gastrostomy tubes. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. The health and personal care needs of people living at the home are well met, promoting health and well-being and ensuring that they receive medication in a safe and consistent manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People’s health care needs had been recorded in their care plans. In some instances the needs were quite considerable due to complex disabilities. Pressure risk indicator assessments were in place on care plan files to evaluate likelihood of developing damage to the skin. The format being used did not have a prompt to remind staff to add the date that the assessment was carried out on or a place for the assessor to sign the document. It was therefore not clear when the assessments were carried out and a recommendation is made to address this. Dependency level assessments had been carried out in November 2007 and a copy was on each person’s file. The building had been adapted to accommodate wheelchairs and had the necessary hoisting, adapted bath and shower equipment in place to assist with daily living tasks. Daily records showed that staff respond promptly to any health concerns and have good working relationships with the health care professionals involved in people’s care. One of the service users had attended a doctor’s appointment during the morning of the inspection and the member of staff who had accompanied her had promptly noted the doctor’s diagnosis Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 14 and treatment plan in her records. Service users’ weights were being recorded in their care plan files and records of appointments attended were up-to-date and showed access to routine and specialist health care facilities. Records of seizures were being maintained where necessary. A protocol for the administration of rectal diazepam on one person’s file had been photocopied and was undated and not on headed surgery paper. It is recommended that any such protocols are re-issued to make sure that they are in proper order and reflect current care needs. A doctor wrote “I have found the staff to be very helpful and very caring. Whenever I have seen the clients as patients I have never had any concerns about their care. They all seem very happy and well looked after.” A relative said that the home ‘always’ met care needs. Medication was being managed well and safely. The home was using a monitored dose system of medication administration and had samples of staff signatures to show who was completing administration records and photographs of service users. Copies of prescriptions were attached where staff had handwritten new medicines onto record sheets. Written authorisation to use homely remedies, such as pain relief and over the counter creams, had been agreed for each person by one of the doctors. Records were in good order and the cabinets were secure, a medicines fridge had been ordered in the event of anyone being prescribed medicines that require refrigeration. The home’s pharmacist had visited the service in January this year and was pleased with arrangements in place, stating “I was pleased to see all these additions evidenced (referring to previous recommended actions). Well done!” Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. Complaints and adult protection are effectively managed to listen to views of people who live at the home and reducing the risk of harm to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The organisation has a complaints policy in place and those people who completed surveys were aware of how to raise any concerns if they had issues with care practice. A complaints log was being maintained to record any compliments or complaints. There had been one complaint at the home which had been responded to by the operations manager for the service. The Commission has not been contacted directly by any of the service user’s representatives with complaints. In the pre-inspection self-assessment the manager said that there had not been any adult protection issues occurring in the past twelve months. The Commission is not aware of information to the contrary. A detailed adult protection/safeguarding procedure was in place which clearly sets out the different types of abuse and staff responsibilities to report it. A whistle blowing procedure was also in place. Staff training records showed that the team had received appropriate adult protection training. Recording of people’s well being, any signs of ill health, accidents and any skin marks was being maintained to a good level. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is excellent. The home is clean, well decorated and adequately maintained, promoting a positive environment for the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cotswold Cottage is a large detached property at the end of a quite residential road in Hazlemere and overlooks farm land. Each person has a single room and there is accommodation on two floors. The personality and interests of service users are evident from their rooms as they have been individually decorated and personalised to a high degree with provision of sensory equipment where people’s needs indicate this. Corridors and the lounge contain photographs of users, some going back to early years, supplied by families. Doorways are wide enough to allow wheelchair access and bathrooms and toilets have been adapted downstairs to meet the needs of people with physical disabilities. Flooring in bathrooms, the laundry and kitchen is non-slip, all rooms apart from the office were in good decorative order and furniture and equipment were in good order. There was good regard for cleanliness and hygiene with no odours in the building despite the high level of incontinence and staff were carrying out good Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 17 infection control procedures through use of individual hoist slings, individual bath mats, wearing of disposable protective items and using anti bacterial hand wash and gel. The kitchen had retained a domestic feel and staff were seen to be around providing supervision if any service users went in there. The garden was tidy and well maintained with plans to add raised beds and a greenhouse to create more interest for service users. There is parking for staff and visitors’ cars and ramped access to the front door. A relative said “The environment at Cotswold Cottage is pleasant, clean and bright and the evidence is that care staff are doing their best to provide a happy and caring environment.” A health care professional said “The home is always in a clean state and has a very ‘homely’ feel to it.” Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 18 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): 31,32,33,34,35,36 Quality in this outcome area is good. The home provides staff cover to meet needs and undertakes thorough recruitment procedures, with effective training to ensure staff have the right skills and competencies to support the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cotswold Cottage had around 50 vacant staff hours at the time of the inspection, which were being advertised as two part time posts. Cover of the home was being maintained through use of relief staff, some permanent staff working additional hours and minimal use of agency staff. For the week prior to the inspection, one shift had included an agency worker and the home had received information about that person’s recruitment checks and training beforehand. The rota showed that appropriate levels of cover are being maintained to meet people’s care needs. A notice board with photographs and names of staff was being used to show service users who was on duty. There had not been much change within the staff team. One person had left, another had been promoted to assistant manager. The file of the newest member of staff was looked at to see what recruitment checks had been carried out. There was evidence of satisfactory POVAfirst and Criminal Records Bureau clearance, two written references, a completed application form and proof of identification. Occupational health clearance had been given. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 19 Training records of three staff showed that they are up-to-date with mandatory and specialist courses such as epilepsy awareness. Overall, the staff team had achieved a 69 level of National Vocational Qualification achievement. Roles and responsibilities of staff are outlined in job descriptions and reinforced through regular supervision and staff meetings. Some staff meetings had fallen by the wayside over a period of time where the manager has been overseeing another service but this does not appear to have affected quality of care or continuity for service users. Staff have continued to work in partnership with outside agencies such as dieticians and district nurses due to the complexity of care needs and seek advice when they need to. Daily reports and other records have been completed to a good standard. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 20 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): 37,39,40,42 Quality in this outcome area is good. The management and administration of the home promote continuity and quality of care for the people who live there and ensure that risk is safely managed to reduce the likelihood of injury or harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a registered manager with the appropriate qualifications and experience to manage the service. Since the last inspection she has spent time overseeing another service which has meant that her time at Cotswold Cottage has been much reduced although she was able to maintain attendance at reviews and consultation meetings. The quality of people’s care does not appear to have been jeopardised by this arrangement but it is good to know that she is back permanently now. Monitoring of the service is undertaken through service monitoring visits carried out by the operations manager, quality audits (one was booked to take place the same week as this inspection, unknown to the Commission for Social Care Inspection) and through visits on behalf of the provider. There were only Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 21 eight reports of visits undertaken on behalf of the provider for the past twelve months which could indicate that the full complement of reports has not been forwarded to the service. A recommendation is made to address this. Records were overall in good shape with a new system in the office reflecting a corporate approach to record keeping. The service had numerous policies and procedures to refer to for guidance and support in an operations manual. Policies and procedures containing the contact details of the Commission for Social Care Inspection will need to be updated to include the new regional address in Maidstone, Kent, so that staff and the public have the correct details to hand; a recommendation is made regarding this. Health and safety was being effectively managed. Certificates were in place to show gas safety and safe electrical installation. Portable electrical appliances had been safety tested in April last year. Water had been tested last year for the presence of organisms and was found to be satisfactory. The fire alarm had recently been serviced and extinguishers were serviced in August last year. Hoist and bath servicing had been carried out recently (certificates awaited). Staff were recording accidents and had attended relevant health and safety training as part of their mandatory training profiles. Standards of cleanliness and infection control were good and the necessary equipment and adaptations were in place to meet people’s needs. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 x 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 4 25 3 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 3 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 3 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 3 x 3 x x 3 x 3 x Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Refer to Standard YA6 YA19 Good Practice Recommendations Evidence of regular reviewing of information on care plan files, and changes where necessary, is needed to show that documentation is still current to people’s care needs. The date of assessment and who undertook it is to be noted on the pressure risk indicator evaluations (Waterlow) so that it is clear to see when these were produced and by whom. Individual protocols on the use of rectal diazepam need to be re-issued by the doctor or specialist in order that they are up-to-date and dated. All reports of visits undertaken by the provider should be forwarded to the home, to show that monitoring has taken place monthly. Policies and procedures containing the contact details of the Commission for Social Care Inspection are to be updated to include the new regional address in Maidstone, Kent, so that staff and the public have the correct details DS0000022965.V359275.R01.S.doc Version 5.2 Page 24 3 4 5 YA20 YA39 YA40 Cotswold Cottage to hand. Cotswold Cottage DS0000022965.V359275.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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