Inspection on 11/08/05 for Coplands Nursing Home

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Coplands Nursing Home 11/07/07

Coplands Nursing Home 16/05/06

Coplands Nursing Home 10/10/05

Coplands Nursing Home 25/01/05

Coplands Nursing Home 11/05/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Coplands Nursing Home 1 Copland Avenue Wembley Middlesex HA0 2EN Lead Inspector Ram Sooriah Unannounced 11 August 2005, at 8:30am 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 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. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Coplands Nursing Home Address 1 Copland Avenue Wembley Middlesex HA0 2EN 020 8733 0430 020 8733 0450 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Life Style Care PLC CRH Care Home with nursing 77 Category(ies) of OP Old Age 65 years and over 46 registration, with number DE Dementia 65 years and over 15 of places PD Physical Disability 16 Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th January 2005 Brief Description of the Service: Coplands Nursing Home is a purpose built care home, which belongs to Lifestyle Care Plc, a national provider of care homes. It is situated at the junction of Coplands Avenue and the Harrow Road. As such it is accessible by buses, which pass on the side of the home. The home has a large parking area at the back. It is close to Wembley and to Sudbury, where shops and local amenities can be found. The front of the home is paved and has a small garden area with shrubs and bushes. There is also a back garden and patio area, which are accessible to service users. The home has accommodation for 77 service users in single bedrooms, which are en-suite. It caters for service users with a range of needs and is divided in 5 units. The Falcon unit is situated on the ground floor and has 16 beds for young physically frail service users. The Owl unit also on the ground floor has 9 beds for frail elderly service users; the Hawk unit situated on the 1st floor also caters for the needs of frail elderly service users (20 beds) and the Eagle unit (15 beds) accommodates elderly service users with dementia. The Kestrel unit (17 beds) specialises in the care of frail elderly Asian service users. There were 74 service users in the home at the time of the inspection. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first of the two statutory inspections for the period 2005-2006. It started at about 0830 and lasted until about 1900. The inspection was conducted by Ram Sooriah and was assisted by Virginia Allen. During the course of the inspection, the inspectors were able to observe service users getting up in the morning, the serving of meals and the care practices in the home. The inspectors also spoke to service users, visitors, the manager and some members of staff. They looked at care and medicines records, inspected the premises and checked for compliance with past requirements. In this report the inspector refers to Ram Sooriah and the inspectors refer to Ram Sooriah and Virginia Allen. The inspectors would like to thank the service users, visitors, the manager and her staff for a kind welcome to the home and for their cooperation and support during the inspection. What the service does well: What has improved since the last inspection? Pressure area care and wound care provided to service users with pressure sores have improved. There has been some improvement in the involvement of service users/representatives in the care planning process. The home has conducted a review of staffing on some units, which has led to some improvement in staffing levels. The shared en-suite bathrooms on the Falcon unit have been altered to make single en-suite bathrooms. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 6 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. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 and 4 The home provides Asian service users with information about the home in the service users guide, which has been translated in Gujurati. The assessment of the needs of service users was not always comprehensive enough to ensure that the needs of service users were clearly identified. Once the needs of service users changed, re-assessments and reviews of the needs of service users were not always documented to demonstrate that every steps had been taken to ensure that the needs of the service users were being met. EVIDENCE: The inspector noted that bedrooms of service users had service users’ guide and that these were translated in Gujurati for Asian service users, who on the main spoke Gujurati. Copies of the statement of purpose and of the service users’ guide were also available in the foyer of the home together with the latest inspection report. The inspector looked at four care plans, two at random, and two for identified service users for case tracking purposes. He noted that the needs assessments of service users were not always completed comprehensively. The section on Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 9 communication for a service user did not clarify the ability of the service user to express herself, and about her particular behaviour with regard to communication. The section on sleep for one service user did not clarify the sleeping pattern of the service user. The section on mental health assessment was not always completed to describe the behaviour of service users and the mental health needs of the service users as a result of their mental illnesses. As a result, there is no guarantee that the home will be able to meet the needs of the service users if these have not been identified. The inspectors observed that a service user with mental health needs was on a unit for elderly frail service users. After looking at her care records, the inspectors concluded that her needs should be reassessed and discussed in a review meeting to ensure that her needs were being met in the best ways possible. The inspector was informed that there was only one trained nurse who was a qualified mental health nurse on the unit for service users with dementia. Staff on the unit confirmed that they wanted more training in areas of mental health and dementia, to increase their confidence and expertise to care for service users who have mental health needs. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-10 Some progress has been achieved in the involvement of service users/representatives in the care planning process. Care plans are reviewed monthly or more regularly but could have been more comprehensive to ensure that identified needs of service users were being addressed. Service users’ healthcare needs were generally being met, but more records could have been kept as evidence that service users were seen regularly by the optician. Medicines management in the home was not always carried out as safely as was possible. While on the whole service users’ privacy and dignity were respected a few issues were identified where the privacy and dignity of service users could have been compromised. EVIDENCE: Service users had individual care records which were in good order and which were kept securely at nurses’ stations. Care plans were in place for service users, where particular needs had been identified. There has been some improvement in the general content of the care plans, but in a few cases the care plans could have been more comprehensive. In the case of a service user who was diabetic, the care plan mentioned to observe for signs of hypo and hyperglycaemia but it did not describe the signs and symptoms to observe. It Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 11 also did not state what actions to take in these cases. Another service user who would not sit long enough for her to take a full meal, because of her restlessness, did not have an action plan to deal with this problem. The inspectors noted that care plans were reviewed monthly or more often for short-term problems. The home uses a range of risk assessments, which were also reviewed at least monthly. This is good practice. There was evidence in some care records that service users and/or that their relatives were consulted in drawing care plans. The manager stated that she has been writing to those relatives/representatives of service users who have not been to see the care plans to make arrangements to discuss the care of the service users. She also explained that the home would be arranging six monthly reviews with service users/relatives to discuss and agree the care plans. This is an area where there has been improvement and the home should be commended. All service users during the inspection presented as clean, appropriately dressed and groomed. The inspector noted that there has been good progress with regard to meeting the needs of service users with pressure sores. Care plans, assessments and photographs were in place in cases where service users had pressure sores. There was a description of the pressure relief equipment in place and there was evidence that the Tissue Viability Nurse was consulted about the management of pressure ulcers. The staff are to be commended for progress achieved in this area. Service users in the home are mainly registered with one GP, who was doing a round on the inspection day. Records showed that service users were seen by a number of healthcare professionals including the psychiatrists, dietician, speech and language therapists, dentists and opticians. Records were however not always clear to show whether service users were seen by the optician at regular intervals. The inspector observed that a service user was sliding down his chair continuously. His records showed that he has not been referred to an occupational therapist for an assessment of his seating from which he could benefit. All service users had an individual continence assessment. These generally described the incontinence aids being used by service users to manage incontinence. They did not however mention the times for changing the pads and whether individual service users were being offered the opportunity to use the toilet or commode. They instead seemed to indicate that the management of incontinence/continence involved the changing of pads with no active interventions for the promotion of continence, even for newly admitted service users. As a result the registered person must ensure that the continence assessments/care plans to manage incontinence/continence of service users are more comprehensive, to include the frequency of toileting and change of pads and that the plan is not only to manage incontinence but includes the promotion of continence where possible. The inspector looked at medicines on the Hawk and Kestrel Units. The general management of the medicines in the home was mostly appropriate but a few Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 12 issues were identified which could put service users at risk. The inspector noted that there were some omissions with regard to medicines charts being signed when a medicine has been administered or a code used if the medicine has not been administered. Receipts of medicines in the home were also not always recorded. The medicines room was 28 degrees centigrade on the Kestrel Unit on the day of the inspection. Temperature readings were normally taken by night staff and were therefore generally cooler and were around 23 degrees centigrade. These were likely to be much higher during the course of the day. The registered person must ensure that medicines are stored at temperatures below 25 degrees centigrade. A medicine for a service user was omitted for three days because the medicine was not ordered. The registered person must ensure that there is a constant supply of medicines to ensure that the service users have their medicines at regular intervals. The inspectors noted a number of medicines in a service users’ bedroom on a set of drawers and which needed to be kept locked. The nurse immediately locked them away when these were pointed to her. While talking to staff, the inspector was informed of a service user who needed her medicines crushed, as she was unable to take tablets. Tracking of her records showed that there was no risk assessment in place with regard to the crushing of medicines, as would be appropriate for medicines which need crushing. A service user was prescribed diazepam to be given per rectum when having epileptic fits if that was required. There were no care plan or protocol to guide staff with regard to the administration of the diazepam, number to be administered and what to do if fits persist. Nurses had some knowledge about medicines, but the knowledge could have better with regard to indications for use and side effects to observe for. The home had en-suite bathrooms, which were shared on the Falcon unit by two service users. These could be accessed from either room posing a problem with regard to maintaining privacy. The problem was being rectified at the time of the inspection and work was nearly completed with regard to separating each of the shared en-suites into two smaller en-suite bathrooms accessible only from one bedroom. The inspectors however noted workers going into the rooms of service users while personal care was being delivered to service users. The manager agreed that this was inappropriate and produced a risk assessment with regard to the building work (a copy was also in each bedroom on the Falcon unit) and stated that she would address this issue with the workers. The inspectors observed care practices and noted that service users were addressed appropriately by staff, except on one occasion when a carer used an inappropriate strategy to coax a service user to eat breakfast, by using the fears of that service user. The inspectors also observed that the private fridge of a service user was being used to store food items that did not belong to him. A number of service users on the Kestrel Unit were not wearing socks, slippers or shoes. Reasons provided for this were unclear. It is therefore recommended that service users have socks, slippers or shoes unless it is the preference of service users to remain bare footed. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 13 Wardrobes contained a number of items of clothing including shirts, T-shirts and trousers, which were not ironed. A service user was observed wearing a cardigan, which looked creased. The inspectors noted that a service user who stayed in his room on the Kestrel unit did not have a call bell close to him to summon help if that was required. The registered person must ensure that the privacy and dignity of service users are maintained at all times by addressing the above issues. The inspector also recommends that staff have training on Dignity and Privacy to gain more understanding on these issues. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 The home provides a range of social, cultural, religious and recreational activities to meet the needs of the service users. While meals provided were generally suitable for the needs of service users, some ‘fine tuning’ of meals was required on the Asian unit. At the time of the inspection, breakfast was being provided at 0945 on one unit. The late serving of breakfast could compromise the nutritional status of service users. EVIDENCE: The home has four activities coordinator, some part-time and some full-time. On the day of the inspection, a music session was arranged for the afternoon. In the morning there was a reading of religious books on the Asian unit. Some service users were also booked to go into the multi-sensory room. There were comprehensive assessments of the social and recreational needs of service users available for inspection and care plans were in place to address the needs of service users. There were also records of the social activities that service users took part in. Programme of activities were available on each unit. The manager informed the inspector of activities that were being arranged for the weekend. There was evidence of outings being arranged. The home uses Dial-a-Ride for some of the outings to shopping centres, parks, temple and mosque. The inspector was informed that a picnic has been arranged in the local park to take place a few days after the inspection. A few of the service users on the YPD unit attend day centres and go out on their own. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 15 The home has an open visiting policy. The inspectors observed a number of visitors in the home. They were able to meet the service users in the bedroom of the service users or in the communal areas. Visitors were generally happy about the way they were received in the home. The inspector was informed of a number of religious people who visit the home to offer spiritual support for service users. There is a multi-denomination room on the second floor for service users. The inspectors observed some service users moving between different areas on the units such as between their rooms and the communal areas. Some service users also opted to stay in their rooms and other preferred to use the communal areas. There was evidence that service users were able to bring personal possessions with them when they moved into the home. Other areas where the inspectors observed service users being offered choices includes choices for meals and choices for taking part in activities. The home has a main kitchen, which caters for the majority of the service users and a smaller Asian kitchen, which caters mostly for the Asian service users. The inspector was informed that evaluation forms were sent to service users/representatives to get feedback about the meals provided by the home. These were apparently sent/received mostly from service users who receive their meals from the main kitchen. The manager stated that the menus for the main kitchen have since been reviewed taking into consideration comments made in the evaluations. The inspectors observed Lunch on the Kestrel and Hawk units and noted that meals were being served appropriately to service users. The kitchen on the Kestrel unit was inspected. It was on the main tidy. The water boiler was not working and the inspectors were informed that the engineers were coming to repair the boiler. It was noted that the necessary records were being kept in that kitchen. The inspectors were informed that fresh vegetables are provided on most occasions. Indeed the fridge contained fresh vegetables. Some service users/visitors however mentioned that the spinach served is not always fresh and is sometimes from tins/frozen. There were some comments that the food on the Asian unit was not as tasty as it could have been, prompting some relatives to bring food for the service users. A few service users/representatives commented that they did not receive one of the evaluation sheets about the meals. As a result the inspector recommends that the evaluations for meals are sent/resent to service users or to the representatives of the service users who take the Asian meals to get feedback on the quality, content and taste of the meals. The inspectors noted that breakfast on the Hawk unit was not served until about 0945. The fact that service users have supper at about 1730 and that some do not always take a snack in the night, means that service users have to go through a period of about sixteen hours without a meal. The manager was therefore asked to provide an action plan within a week to ensure that the breakfast starts at no later than 0900, unless there are service users who request for their breakfast at a later time. This was provided within the time Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 16 scale. The registered person must now ensure that the home works towards meeting its action plan. The home has a number of kitchenettes on each unit. These were mostly clean. The inspectors noted from records kept that the temperature of the fridge on the Hawk unit was running at above 8 degrees centigrade most of the times. On the day of the inspection, the temperature was 11 degrees centigrade. This was the subject of previous requirements, which have not been met yet. The inappropriate temperatures at which food items are being kept could be putting service users at risk. There were some food items, such as fruit juices which did not have a date of opening. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home takes complaints; allegations and suspicions of abuse seriously and deals with these appropriately for the protection of service users. EVIDENCE: The complaint procedure was available in English and in Gujurati. It was offered to service users in the service users’ guide and was also available in the foyer. It was judged to be comprehensive. The home has received a number of complaints and the Commission has received five complaints for the period starting 1st January 2005. Two of these were investigated by the Commission and were partly substantiated. The others were referred to the provider for investigation. Complaints are taken seriously by the organisation and are investigated appropriately. The home has had a number of cases where there has been allegations or suspicions of abuse. In most cases the appropriate procedures with regard to the Protection of Vulnerable Adults were followed. There was evidence that staff have also had appropriate training on Abuse issues and were familiar with the actions that they need to take in cases of allegations or suspicions of abuse. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26 The home is in the main, safe and appropriately maintained to meet the needs of service users. EVIDENCE: The front of the home remained clean, tidy and pleasant. The back of the home was generally tidy. There was a skip, which was being used to clear rubbish from the building work, which was being carried out in the home at the time of the inspection. The building was generally in good condition. Some redecoration works identified in past inspection reports have been completed. The manager stated that she has plans to have the reception area of the home redecorated. The inspector did not look at the redecoration and refurbishment plan on this occasion as the manager stated that she was still in the process of drawing up the plan. The carpet in a few areas on the Kestrel and Eagle units, particularly around the doorways, was becoming unstuck and needed to be made good. Service users and visitors on the Kestrel unit commented that the carpet has not been changed and that the rooms have not been decorated for a number of years. A Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 19 number of bedrooms in the home, including bedrooms on the Eagle unit, did not look personalised and did not have pictures, photographs or items of decorations. The home was generally clean. There were a few rooms which were slightly smelly, and the manager said that the carpet in these rooms were being shampooed regularly to deal with the smells. The carpet in a few rooms on the kestrel unit was slightly stained and the inspectors were informed that the carpets were going to be shampooed on the day. Areas under the beds and bed frames were noted to be dusty in a number of rooms and must therefore be cleaned. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Some of the units have appropriate numbers of staff, particularly those where the staffing has been reviewed. Other units where there has not been a review of staffing would benefit from a review of staffing levels to ensure that these are adequate to meet the needs of service users accommodated on these units. EVIDENCE: The home was staffed according to its duty rosters on the day of the inspection. There has been a review of staff on the Owl and Falcon unit during the day and on the Eagle, Kestrel and Hawk unit at night. There is now an extra trained nurse on the Owl and Falcon unit for the morning shift and an extra trained nurse for the Eagle, Kestrel and Hawk unit at night. During this inspection, a number of staff of the day shift on the Hawk unit engaged with the inspectors with regard to the staffing level during the day. There are three carers and one trained nurse to look after twenty service users. Staff raised concerns that the number of staff is not always enough in view of the dependency and numbers of service users. Trained nurses commented that they do not always have the opportunity to have breaks and that they very often have to stay after they finish their shift to update their records. As a result the registered person must conduct a review of staffing on the Hawk unit and other units where there has not been a review. The training and development plan was not inspected on this occasion and the manager stated that it was in the process of being finalised. A training grid was also not inspected. The inspector was informed of staff having had training on Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 21 wound care and pressure sore prevention. Reports following statutory monthly visits by the provider show that training in a number of areas is being provided for staff. This includes food hygiene, manual handling, fire training and NVQ training. The inspector has given a rating to standard 30 on this occasion, as he did not inspect all the records with regard to training. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 22 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The home has a new manager in post. It was not possible to make a judgement about the way she would manage the home at this stage, as she was new in post. There is however a good support team consisting of the deputy manager and the regional manager. The health and safety of service users are generally promoted. A few issues were identified which need to be addressed to ensure the safety of service users at all times. EVIDENCE: The previous manager has resigned and a new manager has recently been appointed in the home. She was familiar with the issues in the home and had plans to address a number of these. She is supported by the deputy manager, the regional manager and head office. The inspectors noted that the bedrooms facing the front of the home on the first floor have tall windows, which reach from the floor to nearly the ceiling. It Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 23 is not clear at the time of the inspection if the glass in these windows is shatterproof. The manager after seeking advice on these windows, later confirmed that the windows are stress tested and that they conform to the required health and safety specifications. The inspectors noted that a number of windows in the home did not have restrainers. An action plan was requested within a week to address this issue. An action plan has been received and the report dated 23rd August following monthly visits suggests that all windows now have restrainers in place. The registered person must ensure that the window restrainers are always in good working order and are always in place unless there has been a risk assessment. The home has two shaft lifts, which served the floors of the home. One of the lift stops on the unit for service users with dementia and the lift door opens on that unit. The lift can also be called from that unit. So a service user could call for the lift and enter the lift when it opens on the floor. Although there are electronic locks on all the doors to exit the unit, the way the lift door opens on the unit may suggest a weakness in security. The registered person must therefore carry out a risk assessment with regard to the lift door opening on the unit for service users with dementia, which could enable a service user leave the unit/home unnoticed and potentially put him/her at risk. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x 3 x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 2 Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 25 Yes 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 OP3 Regulation 14(1,2) Requirement Timescale for action 30/11/5 2. OP4 3. OP7 4. OP8 5. OP8 The registered person must ensure that all service users have a comprehensive assessment of their needs. 14(2)(a) The registered person must ensure that the changing needs of service users are assessed and reviewed to ensure that the needs of the service users are being met. He must also review the training needs of staff on the unit for service users with dementia to ensure that they have the skills and experience to care for service users with dementia. 15(1) The registered person must ensure that care plans set out in detail the actions that need to be taken to ensure that the needs of service users are met. 13(1)(b) The home must keep clear records to demonstrate that service users are seen at regular intervals by the optician. Service users must also be referred to the appropriate healthcare professionals such as the Occupational Therapist if that is required. 12(1)(a,b) The registered person must G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc 31/10/5 30/11/5 31/10/5 30/11/5 Page 26 Coplands Nursing Home Version 1.40 6. OP9 13(2,4) 7. OP9 13(2,4) 8. OP9 13(2,4) 9. OP9 13(2,4) 10. OP9 13(2,4) 11. OP10 12(4)(a) ensure that the continence assessments/care plans to manage incontinence/continence of service users are more comprehensive, to include the frequency of toileting and change of pads and that the plan is not only to manage incontinence but includes the promotion of continence where possible. The registered person must ensure that medicines are stored at temperatures below 25 degrees centigrade. All medicines must be stored in a locked cupboard at all times. The registered person must ensure that there is a constant supply of medicines to ensure that the service users have their medicines at regular intervals as prescribed. The registered person must ensure that all medicines charts are endorsed when medicines are administered or a code used if the medicines have not been administered. Service users who are on diazepam for epileptic fits must have a protocol/plan in place agreed with other healthcare professionals about the administration of the diazepam. A comprehensive risk assessment must be in place in cases where medicines are being crushed or being given in an altered state. The registered person must ensure that the privacy and dignity of service users are maintained at all times and must address the following issues: -that the personnal property of service users are not used for other persons unless permission 31/10/5 15/10/5 15/10/5 31/10/5 31/10/5 31/10/5 Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 27 12. OP15 16(2)(i) 13. OP15 13(4) 14. OP19 23(2)(d) 15. 16. OP26 OP27 23(2)(d) 18(1)(a) 17. OP38 13(4) of the service user has been received -that all clothes of service users are ironed appropriately -that non-care staff and other people such as contractors/workers, do not enter the bedrooms of service users while the personal care of service users is being carried out - that service users are given a call bell unless there has been a risk assessment to say otherwise. The registered person must ensure that breakfast starts at no later than 0900, taking the individual wishes of service users into consideration. The registered person must ensure that the fridge on the Hawk unit is repaired or replaced to ensure that food is kept at a temperature of 2-8 degrees at all times. The registered person must ensure that the carpet is made good in areas where it is becoming unstuck. The registered person must ensure that all the bed frames are free from dust. The registered person must conduct a review of staffing on the Hawk unit and send a copy of the review to the Commission. The registered person must carry out a risk assessment with regard to the lift door opening on the unit for service users with dementia, which could enable a service user leave the unit/home unnoticed and potentially put him/her at risk. 31/10/5 31/10/5 31/10/5 31/10/5 31/10/5 31/10/5 18. Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP8 OP9 OP10 OP10 OP15 Good Practice Recommendations It is recommended that service users are referred to an occupational therapist for a seating assessment when problems are identified with seating. The registered person must ensure that nurses administering medicines, have a good knowledge of the medicines including side-effects and indications of use. The inspector recommends that staff have training on Dignity and Privacy to gain more understanding on these issues. It is recommended all that service users have socks, slippers or shoes unless it is the preference of service users to remain bare footed. It is recommended that fresh vegetables are served on every possible occassions to service users, particualrly to those who take the Asian meals (vegetarian). The inspector also recommends that the evaluations for meals are sent to all service users or to the representatives of the service users who are accommodated on the Kestrel unit to gain information about the level of satisfaction and also to receive suggestions about meals. It is recommended that the registered person look at ways to personalise the bedrooms of service users to make them more homely. 6. 7. OP24 Coplands Nursing Home G62-G11 S22924 Coplands Nursing Home V246187 110805 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex HA1 1BH National Enquiry Line: 0845 015 0120 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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