Inspection on 27/04/07 for Cooperscroft Residential Home

This inspection was carried out on 27th April 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cooperscroft Residential Home Cooperscroft Care Home Coopers Lane Road Potters Bar Hertfordshire EN6 4AE Lead Inspector Bijayraj Ramkhelawon Unannounced Inspection 27th April 2007 10:30 X10015.doc Version 1.40 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 Cooperscroft Residential Home DS0000067958.V336687.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 Older People. 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. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cooperscroft Residential Home Address Cooperscroft Care Home Coopers Lane Road Potters Bar Hertfordshire EN6 4AE 01707 644179 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) lpinner@elitecarehomes.co.uk Rockley Dene Homes Limited Lisa Jayne Pinner Care Home 49 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (49) of places Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. When bedroom 25B falls permanently vacant for any reason, it will be removed from the registration. 19th December 2006 Date of last inspection Brief Description of the Service: Cooperscroft is a care home providing personal care and accommodation for 48 older people. It is owned and managed Rockley Dene Homes Limited. The home is situated in a semi-rural location, but close to a junction of the M25 motorway, near Potters Bar. Shops and amenities are a short distance away in the high street. Cooperscroft is a purpose built, three storey building erected in the late 1950’s. Each floor has been divided into two units, each with a comfortable open plan lounge (with T.V) and a diner/kitchenette. A passenger lift provides access to all floors. All rooms are for single occupation with a washbasin. The top floor accommodates up to 14 people with dementia of which two rooms are for respite care. There is ample car parking space at the front and there is a large attractive garden to the rear, mostly laid to lawn with concrete paths. The current fees charged are £550 - £650 per week per person. A copy of the ‘Statement of Purpose’ and ‘Service User’s Guide’ is available at the care home. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced key inspection over one day on 27th April 2007. People living in the care home, visitors and staff were spoken to. A number of individual’s care plans were examined. Policies and procedures and other relevant documents including the management and administration of medicines, staff duty rota, menus, activity programmes, accident and incident records, complaint and compliment book, staff files, health and safety, people’s money and other records were also examined. A tour of the premises and observation of interaction between people living in the home and staff was noted. Cooked lunch was sampled. As from the 1st of October 2006, the home was purchased and managed by Rockley Dene Homes Ltd. The top floor is now dedicated to 14 people with Dementia of which 2 rooms are allocated for respite care. Feedback received from people living in the home and visitors was positive. They were complimentary of staff, food and the services they received. What the service does well: Care practices observed was individualised and dignified. People living in the care home commented that ‘it is good here. Can’t grumble, staff are alright’. ‘I can’t find anything wrong here’. One person who had come in for respite care said ‘ I am in the home for 2 weeks and so far everything is fine. Food is good, too much sometimes. Staff are very nice’. Staff members spoken to were positive about the service provision and appeared committed to their work. A rolling programme of staff training was in place to ensure that all staff completed the required relevant courses. Currently, 70 of the care staff team have completed the NVQ Level 2. Cooperscroft Residential Home DS0000067958.V336687.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. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1-5 People living in the care home has an assessment of their needs carried out prior to an offer of placement being made. EVIDENCE: Care plans examined included an assessment of needs for people. Reports from other professionals formed part of the care plans. Each person had their plan of care and daily living activities based on the assessment of needs. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 7-11 Good care practices and interactions between staff and people living in the care home were observed. Care plans were detailed and comprehensive. However, falls prevention team’s advice should be sought when required and records in MAR sheets should be kept in line with the Royal Pharmaceutical Society Guidelines so that safe practices are maintained. EVIDENCE: People spoken to confirmed that they were well cared for and their individual needs were being met. Care plans had all the information including assessment of needs; health and personal care being provided, risk assessments and how the needs of the people were being met. However, the advice of the ‘falls prevention team’ was not sought when an individual has had falls and sustained fractures to arm, head and pelvis. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 10 People who required nursing care had regular input from the District Nurses. All service users were registered with a GP and a log of visits from them, District Nurses, Community Psychiatric Nurses and all other health care agents was maintained. People living in the care home were appropriately dressed, well groomed and they confirmed that staff addressed them by their preferred names. They also said that they were happy to be at the care home as they felt that their needs were being met. The home has a “knock and wait” policy on entering service users’ bedrooms, toilets and bathrooms. Staff members on duty were observed to deliver care and to attend to service users’ needs in a manner that was conducive to respect for their privacy, dignity, choice and wishes whilst actively promoting independence where possible. There was a relaxed atmosphere and good interaction between staff and people living there. All personal and intimate care practices are carried out behind closed doors. Doctors and District Nurses also see people in the privacy of their own rooms. A policy and procedures for care of the dying was in place. spoken said that they were aware of this policy. Staff members Records of medicines including the receipt, storage, administration and disposal were examined. These were kept in good order. However, generally hand written instructions on MAR sheets were signed by the person making the entries except for few which were not. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12- 15 Autonomy and choices were exercised. A programme of day activities was devised and posted on the notice board. People spoken to confirmed that they did have the opportunities to pursue their leisure, social, recreational and cultural interests. EVIDENCE: There was a weekly programme of activities posted on the notice board. On the day of the inspection, it was noted that people were listening to music, reading newspapers, chatting to each other and watching T.V. Representatives from the local church also hold a hymns session in the home. The mobile library visits the home regularly. Some people manage their own financial affairs with the help of their relatives and for others; the home manages their money handed over for safekeeping. Personal belongings were evident in individual bedrooms. Relatives, social Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 12 workers and solicitors act as advocates for some people living in the care home. The lunch was served unhurriedly with assistance and encouragement given by staff. Tables were laid nicely and a choice of drinks was available and there was individual cutlery. People spoken to were complementary of the food provided. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16-18 The home has a robust complaints procedure of which people living in the care home and visitors spoken to were aware of. Staff confirmed that they have attended training in the protection of vulnerable adults. EVIDENCE: A copy of the complaints procedure was available to people living in the care home. Those spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. Staff files examined and staff spoken to confirmed that they have received training on Protection of Vulnerable Adults. No complaint has been received since the last inspection. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 19-26 The home was kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. However, a programme of routine renewal of furniture that were worn and badly stained should be devised and actioned. EVIDENCE: Accommodation is provided for single occupation on three floors, which are accessible and safe. Each unit has a lounge and a kitchen/diner. There is a no smoking policy for staff in the home and the designated area is outside the building. However, people living in the home can smoke in their bedrooms depending on the outcome of a risk assessment. People who smoked were Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 15 supervised by staff and in some cases their cigarettes and lighters were kept in the office. Each bedroom provides single room accommodation with a hand washbasin. There were sufficient number sanitary and bathing facilities in each unit to meet the needs of people. These facilities were sited within close proximity of each bedroom. Individual’s bedrooms contained personal items and pictures have been hung at their request. People have access to all communal areas, private space and outside the home through the provision of a passenger lift, stairs and ramps. Individual reclining chairs are supplied by the Occupational Therapist following assessments. However, risk assessment was not carried out for an electric reclining chair used in the lounge (see Standard 38). The furniture in the lounges was noted to be worn and badly stained. There was adequate number of domestic staff and records showed that staff have been provided with training in hygiene and infection control. The front and back gardens were well maintained and staff said that the gardeners made weekly visits and regularly attended to the lawn and flowers. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 27-30 The skills and experience of staff were varied. There was an enthusiastic, dedicated and caring staff team who took great pride in the service provision. 70 of the care staff team has already completed the NVQ Level 2. However, staff files examined for newly appointed staff did not advocate a robust recruitment system was being followed so that people in the home is protected. EVIDENCE: There was adequate number of staff rostered on duty per shift during the day and night. There were also adequate number of domestic and catering staff allocated per day and the home has the services of a fulltime maintenance person. People living in the home were complimentary about their rooms, staff and food. They said that ‘ staff are good, they look after us and are very kind’. Food is nice too and plenty. 4 staff files for newly recruited staff were inspected. These showed major shortfall in that one staff did not have any written references, another had Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 17 copies of references transferred from the care agency when the staff worked for that company as acceptable references for the care home. None of these four files contained completed CRB checks. Two had POVA first check done; one awaiting CRB and the other did not have any. Staff in charge said the member of staff was transferred from the London Borough of Harringey where all the records would have been kept. It was also noted that there was not a programme of induction completed for these newly appointed staff. However, staff in charge said that a new induction programme has been devised by Rockley Dene Homes Ltd and awaiting implementation. Staff spoken to confirmed that they have received appropriate training, this included all statutory training. They also said that they receive regular supervision and an annual appraisal and they have been given a copy of the General Social Care Council Code of Conduct. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31-38 The home has a good management structure and well supported by senior managers from Rockley Dene Homes Ltd. The senior staff who have direct involvement, appear to be dedicated to providing a good quality service. A copy of the monthly providers report is sent to CSCI. Positive feedback from people living in the care home and staff has been received in respect of the support given to the care home by the new management team. However, a list of valuables handed over for safekeeping should be kept and risk assessment for electric reclining chair must be carried so that people are not put at risk. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 19 EVIDENCE: Feedback received from people living in the care home, their relatives and staff was positive since the purchase of the care home by Rockley Dene Homes Ltd from London Borough of Harringey. The management communicate a clear sense of leadership within the home and have an open-door policy where staff could see them at any time with any issues or concerns they may have. People living in the care home and their relatives have commented positively on the good practices and quality of service provision. However, the electric reclining chair kept in the lounge did not have a risk assessment undertaken and how the risk must be managed and minimised. The management of people’s money was kept in good order with all receipts for expenditures and money received being logged. Some peoples money has been transferred to the management of the care home but for others, it still remain to be sorted out. However, there was no list kept for valuables handed over for safekeeping. All statutory records were available for inspection and maintained in accordance with legislation. Records inspected were up-to-date and accurate and were held securely. Staff spoken to were aware that people can access their records and information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of people living in the care home and staff are promoted and protected. These records are accessible to all staff. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The CSCI has been kept informed of all accidents and admissions to hospital. Regular checks on hot water temperatures and moving and handling equipment were recorded. A valid insurance certificate was displayed in the reception area and this offered cover of no less than £5 million. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 2 3 3 2 Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? 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 OP29 Regulation 19 (1) (b) (i) and (c) Requirement Staff files must contain an application form, two written references and CRB check undertaken prior to an offer of employment is made. Risk assessment for electric reclining chair must be carried and an action plan devised to minimise and manage the risk. Timescale for action 29/06/07 2. OP38 13 (4) (c) 29/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP8 OP9 OP19 OP35 Good Practice Recommendations Falls prevention advice should be sought for people who have had a fall so that appropriate action is taken to prevent further incidents (where possible). Hand written instructions on MAR sheets should be signed by the person making the entries. A programme of routine renewal of furniture that are worn and badly stained should be devised and actioned. A list of valuables handed over for safekeeping should be kept. Cooperscroft Residential Home DS0000067958.V336687.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area 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. 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