Inspection on 16/05/06 for Coplands Nursing Home

This inspection was carried out on 16th May 2006.

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 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

Coplands Nursing Home 11/07/07

Coplands Nursing Home 10/10/05

Coplands Nursing Home 11/08/05

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Coplands Nursing Home 1 Copland Avenue Wembley Middx HA0 2EN Lead Inspector Judith Brindle Key Unannounced Inspection 09:00 16 , 17th, 19th May 2006 th X10029.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 Coplands Nursing Home DS0000022924.V296456.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 and 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. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coplands Nursing Home Address 1 Copland Avenue Wembley Middx HA0 2EN 020 8733 0430 020 8733 0450 coplands@lifestylecare.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Life Style Care Plc Lynne Marie Beckley Care Home 77 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (46), of places Physical disability (25) Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No more than 77 persons in need of nursing care may be accommodated at any one time. Categories of care are Elderly Mentally Ill, Elderly Frail and YPD Minimum staffing notice applies Temporary variation agreed for one named individual (Mr SS) aged 59 years for the duration of his stay No less than 37 places and up to 46 places for older people during the transition of Owl unit from older people to younger adults. 10th October 2005 Date of last inspection Brief Description of the Service: Coplands Nursing Home is a purpose built care home, which is owned by Lifestyle Care Plc, a national provider of care homes. It is situated at the junction of Coplands Avenue and the Harrow Road. The variety of shops, banks, and restaurants and other amenities of Wembley and Sudbury are located within a few minutes walk from the home. Public bus and train transport facilities are accessible close to the home. The home has a large car parking area at the back of the home. 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 ensuite. It caters for service users with a range of needs and is divided in to 5 units. Falcon unit is situated on the ground floor and has 16 beds for young physically frail service users. Owl unit also on the ground floor has 9 beds, which was accommodation for frail elderly service users; but the care home has recently registered with the Commission for Social Care Inspection to increase the numbers of registered places for adults with a physical disability from 16 to 25, and these residents will be accommodated in Owl unit. Hawk unit is situated on the 1st floor and caters for the needs of frail elderly service users (20 beds). Eagle unit (15 beds) accommodates elderly service users with dementia care needs. Kestrel unit (17 beds) specialises in the care of frail elderly Asian service users. The fees range from £560-1500, and additional charges are clearly recorded in the service user guide and the residents’ contract/terms and conditions. The home provides service users, and visitors with information about the care home, which is available in Gujarati. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 3 days in May 2006. The lead inspector was assisted for a day and a half of the inspection by another regulation inspector. The Commission for Social Care Inspection pharmacist inspector inspected the medication National Minimum Standard for care homes. The registered manager had supplied the Commission for Social Care Inspection pre-inspection information and documentation, which considerably assisted the inspectors in the process of this inspection. The inspectors were pleased to meet, and speak with many of the service users, some relatives/visitors, and several staff on duty including the cooks, and the staff member who carries out laundry duties. The purpose of the inspection was to spend time with the service users, and to gain their views of the service, assess key National Minimum Standards, and to follow up and assess as to whether previous inspection requirements and recommendations had been met. The inspectors spent a significant part of the inspection on the units talking with service users, and observing interaction between service users and staff. Several service users’ communication skills were varied, and many had difficulty communicating their views of the service, so observation was a major tool in the inspection process. The inspection included a tour of the premises, inspection of service users’ care plans, staff personnel records, medication storage and administration records, meals and mealtimes, and inspection of a variety of other records. Owl unit at the time of inspection was undergoing a period of transition to change the unit from accommodating older persons to adults with a physical disability. 19 recorded feedback/comment cards were received by the Commission from service users, and 14 from relatives/visitors. The registered manager was present during the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. Key National Minimum Standards were assessed during the inspection and requirements from the previous inspection were judged as having been met. What the service does well: Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 6 The care home has a welcoming atmosphere. The home provides care and support to service users with very varied and often complex needs, in a purpose built environment. Feedback from relatives and service users was generally positive about the staff, and service users spoke of staff being helpful and caring. Interaction between staff and service users was observed to be respectful. Bedrooms are single and have ensuite facilities. The management of the home is approachable and professional. It was evident that the registered manager has worked hard to improve the service provided by the care home, and is keen to continue this progress. The home employs activity coordinators. There was evidence that some units have access to varied and preferred activities, which include trips out in the community. What has improved since the last inspection? What they could do better: Service users’ assessment information needs to be fully recorded. Care plans need to continue to be further developed to ensure that service users’ comprehensive needs are being met. Some risk assessments need development. The system for the recording of complaints and ‘concerns’ needs to be reviewed to ensure that there is assurance that service users (and others) are listened to and that there is appropriate action taken in response to ‘concerns’/complaints. The environment continues to need further decoration, and the systems for maintenance in the care home should be reviewed. There are several items that need repairing or replacing. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 7 The activity programmes in some units could be improved to ensure that the preferences of all individuals living in the care home are met. There should be systems in place to ensure that activities are provided to service users when the activity co-ordinators are not on duty. Reporting and recording of accidents/incidents could improve. The presentation of meals could be improved. 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 DS0000022924.V296456.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (6 is not applicable) Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents receive an initial assessment of their needs prior to their admission, but further individual needs assessment information was not always fully documented. EVIDENCE: The care home has an admission procedure. 14 care plans were inspected (between 2 and 4 care plans from each unit). These recorded evidence that prospective service users receive an initial assessment of their needs in their current setting prior to their admission to the care home. The registered manager generally completed this assessment. This documentation is detailed and generally allows staff to determine if/how the care home can meet the prospective service users’ needs. There were significant gaps in recording Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 10 further assessment information including the ‘lifestyle care needs assessment’, and it was not always clear when and who completed this documentation. Assessment documentation focused well in regard to health and care needs, but aspects of social and cultural needs (religion was generally completed but details of how to meet these needs were not recorded) were lacking in some assessment documentation. There was little recorded evidence of service users having been involved in the process of assessment of their needs. There was some evidence of occupational therapist assessment, speech therapy assessment and of assessment by the purchasing authority. Care plans are developed from the initial needs assessment. The manager and relatives confirmed that service users and relatives/significant others have the opportunity to visit the care home prior to their admission to the care home. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7,8, 10 (9 was inspected by the pharmacist inspector) OP. Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users health and personal care needs are met, and that service users are treated with respect and their right to privacy upheld. There needs to be further development in care plans to ensure that staff have knowledge and understanding of how to meet all service users’ needs. EVIDENCE: Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 12 Staff spoke of care plans having been developed and improved. Care plans inspected recorded assessment and some comprehensive staff guidance to meet assessed needs. The care plans inspected generally included good detail of many of the key needs of service users, and assessment of new needs. There are key areas that need to be developed. These include night care needs, individual financial support needs, cultural needs, non-verbal communication needs, and specific activity needs (there is some evidence of activity needs being recorded but this is not evident in the care plans), and further development of some existing recorded staff guidance such as in regard to meeting behaviour changing needs. Feedback from service users confirmed the particular need for assessment of individual service users’ night care and support needs. This was discussed with the registered manager. There were a number of risk assessments in place, such as for pressure care, nutrition, manual handling, and of falls. It was not always evident what the actions are to be taken as a result of these assessments, and at times staff guidance/action is not clear. For example, there was not clarity about the frequency of when a service user had their position changed (‘turned’) in bed; another care plan did not record guidance in regard to pressure area care during the daytime. Risk-taking documentation was not always fully completed. There was evidence that the care plans were generally reviewed on a monthly basis, but there should be evidence that the recorded staff guidance is also reviewed regularly. Signatures of relatives were recorded in some of the care plan documentation such as the admission form, documenting personal details and needs, and preferences. Evidence of agreement of the care plans (and their updates) by service users and/or their representatives was generally lacking. A visitor spoke of plans to attend a review meeting of service users’ needs. There was a lack of fully completed assessments and consent for the use of bedrails. Some documentation including fluid monitoring was recorded, but some recording of drinks drunk by service users was documented at the end of the shift rather than at the time that the drinks were drunk by the service user. There was not evidence that this documentation was monitored or reference to the amount of fluids the service user was assessed to need. This could lead to inaccuracies and service users having symptoms of dehydration. Other monitoring including bowel charts should be more detailed to ensure that staff action is taken if symptoms such as constipation occur. Records informed the inspectors that residents were registered with a GP, and referrals to specialists were generally made as needed. Referrals to dieticians where generally made. However there was no evidence that a recently admitted service user with high assessed nutritional needs had been referred to a dietician. Records confirmed that service users received chiropody care, dental care and optician care. Some specialist needs were not always identified in the care plan. An example of this was that staff guidance to meet a service users’ diabetic needs did not include the need for chiropody Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 13 treatment and regular specialist eye checks. It was not evident from care plan information that a service user had attended a hospital appointment for an eye check in relation to her diabetic symptoms. A service user spoke of being ‘looked after fine in terms of health’. Service users who kindly spoke with the lead inspector confirmed that they received specialist healthcare treatment. There were no concerns in regard to service users’ clothing, though some service users spoke of laundry items going missing. There was evidence that systems had been put in place to improve the laundry service and that this was being monitored (see Standard 26). Staff feedback confirmed that they had a good knowledge and understanding of service users’ varied needs. There was evidence from observation and feedback that service users received individual care and support. There was evidence from two units that service users did not always have a member of staff with them in the sitting rooms. A staff member reported that this was needed to ensure that staff are available to meet service users’ general and specific needs. Systems should be in place so that service users’ needs are met at all times. A tour of the care home confirmed that there was equipment necessary for the promotion of tissue viability and the prevention of pressure sores. Staff were observed to respect service users’ privacy and dignity during the inspection. 15 written feedback/comment cards from service users confirmed this. Two feedback responses recorded ‘sometimes’ their privacy was respected, one recorded that their privacy was not respected. The care home should have an accessible recorded gender care policy/procedure in regards to the provision of personal care to service users. Staff informed the lead inspector that there was not a payphone in Eagle unit, and that the unit shared a payphone with another unit. The registered person should consider putting in place a payphone on Eagle unit for service users’ use. The Commission for Social Care Inspection pharmacist inspector inspected the medication National Minimum Standard and requirements from this assessment are included in this report. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,13,14, 15 (Older People) 12,13,15 and 17 (Adults 18-65) Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that there are social activities organised for service users, but there needs to be development in the activity programmes in some units. The visiting arrangements are flexible and meet the needs of the service users and visitors. Arrangements are in place to enable service users to make choices about their lives. Meals provided are varied and wholesome. Further development is needed in ensuring that the cultural needs and preferences of service users are met as far as possible. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 15 EVIDENCE: The care home employs four activities co-ordinators. An activity co-ordinator informed the lead inspector of the variety of activities that are provided to service users. She reported that activity equipment is accessible to care staff, when activity co-ordinators are off duty. Staff informed the lead inspector that the registered manager had purchased ‘lots’ of activity equipment since being in post as manager. Daily records of activities completed by service users were recorded, and there was some evidence of service users’ social assessments having been recorded. An activity co-ordinator reported that each service user receives an annual social assessment. 16 recorded feedback/comment cards from service users confirmed that they felt that there were enough activities provided. One feedback form recorded that there were not enough activities. During the inspection, both inspectors did not observe much evidence of activities taking place during significant periods of the day on four of the units. The lead inspector was informed that the reason for one unit not having activities during one day of the inspection was due to the part time activity co-ordinater for that unit being on leave. There needs to be a system in place to ensure that service users have the opportunity to participate in activities on days when the co-ordinaters are not there. It is recommended that there arrangements are in place for care staff to assist activity co-ordinators with activities for service users, so that all service users have the opportunity to participate in activities regularly. The notice board in Hawk unit had the incorrect date and staff names recorded, and there was no activity recorded in the appropriate section of the notice board. Verbal feedback from a service user reported that activities were not always age appropriate, varied, and that there were not enough trips out. A visitor commented that service users lacked opportunities to exercise. Activities that took place during the inspection included a music session and a religious/cultural activity (in the unit for Asian elders). On several units televisions were on all the time. Several service users were observed (on Hawk unit and Kestrel unit) to be watching and spoke of enjoying an Asian television channel. Service users were observed watching television and reading newspapers. The inspectors were informed that activities provided included shopping trips, art crafts, skittles, exercises, and participation in the gym of a community centre. Comments from service user about day trips out were positive. The registered manager spoke of accessing the Local Authority transport for trips out, but the care home should consider having its own transport. It is recommended that there are systems developed such as a mobile shop to enable service users to purchase their own toiletries and snacks etc, when there is not the opportunity to access the community amenities. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 16 Records informed the inspectors that a number of service users go to bed between 5 and 6pm in Owl unit, and after supper (17.30pm) on some other units. Staff stated that this is in response to service users getting up early, and in regard to their specific assessed needs, and that they have the choice to go to bed later if they wish. It should be clearly documented in service users care plans their preferred times for bed (with subject to change in line with service users’ preferences). 14 recorded feedback/comment cards from service users received by the Commission for Social Care Inspection in January and February 2006 confirmed that they enjoyed the meals, and 4 feedback forms recorded that they did not like the meals. Asian service users have culturally appropriate meals provided from a separate kitchen in the care home. Service users during the inspection were generally positive about the provision of these meals. Two Asian service users spoke of enjoying the food. Another service user spoke of some Asian meals being repetitive and that occasionally food was ‘hard’. The cook (who provided meals for the Asian service users), and the manager spoke of gaining feedback on a regular basis from service users about the meals, and of improvements being made. This cook was aware of service users’ likes and dislikes, and of any specialist dietary needs. It was found that the only West Indian food supplied on Owl unit, which has a significant proportion of West Indian service users, is at Friday lunchtimes. The cook reported that rice is always offered at meal times for this service user group. There needs to evidence that these service users’ (and others, including Arabic, Polish etc) cultural needs and preferences are being fully met in regard to the provision of meals. A service user spoke of wishing that he could have a particular food item. Following consultation with service users, snacks and drinks should also be provided that meets their cultural needs and preferences. There should be evidence that service users have the opportunity to have particular preferred foods on occasions. This was discussed with the cook, and she reported that she would aim to achieve this. The inspectors were present during breakfast time on three units. The presentation and provision of breakfast on Hawk unit needs to be improved. Service users were sometimes asked to choose what they wanted to eat/drink. There were few service users who sat at tables in the dining area, most were provided with breakfast on a portable table where they were sitting. Tables were not laid for breakfast, and plates and bowls were often plastic. There were few napkins, and no tablecloths, no pots of tea, and no marmalade or jam on the tables. The lead inspector did not hear whether service users were asked if they wanted jam/marmalade. There should be more evidence that choice is offered to service users during meals. One service user told the inspector her toast was dry, and she left three out of four slices. Cold toast Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 17 was provided to service users on Owl unit. Breakfast on the three units was served at approximately 9.20 – 9.40 am during the inspection. This time for breakfast for service users could be regarded as late, particularly if service users had not eaten since their evening snack. The registered manager took action prior to the end of the inspection and assured the lead inspector that service users would all be provided with breakfast by 9.00am and that the presentation of the meal would be improved. Procedures for improved presentation and provision of meals, particularly breakfast needs to be in place in the units were it is presently unsatisfactory. Service users who spoke with the lead inspector spoke of enjoying the lunches served during the inspection. It appeared to be nutritious and wholesome. The lunch in Falcon unit was seen to involve interaction/chatting between service users. This was not so apparent on some other units were service users did not generally sit at dining tables for their meals. The inspector had a sample of the food and found it to be of reasonable taste but that the vegetables might be hard to chew for some service users. Service users varied in their opinions of the food, more commenting positively (one complainant saying poor), but none were able to clearly say that they are provided with a choice, despite there being a choice system in place in writing to help the cook plan the meals. It was also found on Falcon unit that the menu on display was not up-to-date, and that in other units the menu lacked the recommended pictorial support. The manager showed the inspector examples of menus formatted for location on the dining tables. These were not evident on the tables on some units. It was positively fed-back on both units that staff vary the foods of more dependent service users to try to work out what foods they enjoy. This includes providing semi-lunches at breakfast where the service user has indicated that they prefer not to eat lunch. Complaints/’concerns’ about meals need to be recorded (see Standard 16). Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that people are safe living in the care home and know who to talk to if they are dissatisfied, but there needs to be some development in reporting and recording procedures. EVIDENCE: The home has a complaints procedure. This is recorded within the statement of purpose documentation. The lead inspector was supplied with an updated service user guide brochure. The complaints procedure was not recorded in nor attached to the documentation supplied to the inspector. The registered manager reported following receipt of the draft inspection report that the complaints procedure is normally attached to the service user guide, and she supplied the Commission with a copy of the procedure. The registered person should consider including a summary of the complaints procedure in the service user guide to ensure that residents and others are aware of the complaints procedure even if it is not attached to the documentation, as when supplied to the inspector. Pre–inspection documentation received by the Commission confirmed that the care home had received 19 complaints. Records informed the inspector that Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 19 generally complaints are taken seriously by the manager and are appropriately investigated. Staff spoke of verbal concerns/complaints being received by service users, i.e. concerns about the food provision, and that these though responded to, are not always documented. One service user noted that they are unable to make written complaints due to physical disability. A visitor reported some dissatisfaction with the complaints procedure, that on occasions it takes sometime for complaints to be resolved particularly without further interaction from the complainant. There needs to be systems for recording verbal ‘concerns’/complaints and evidence that appropriate action is taken in response these. It is recommended that there is the opportunity for relatives/significant others to regularly meet with management staff to discuss the service provision and any ‘concerns’ that they may have. Two complaints which each included a number of ‘concerns’ were reported to the inspector during the inspection. The registered manager following the inspection investigated both complaints. 15 recorded feedback comment cards from service users confirmed that they knew who to speak to if they are unhappy with their care. 3 recorded that they did not know who to speak to if unhappy about the care, 1 was unsure, and 1 recorded that they would speak to their daughter. The care home has a procedure for the protection of vulnerable adults. There was recorded evidence that appropriate procedures are pursued. All staff except one, who spoke with the inspectors, generally had knowledge and understanding of the appropriate procedures to be followed when there is a suspicion/allegation of abuse. The registered person needs to ensure that all staff are aware of the appropriate procedures to be followed if there is suspicion or allegation of abuse. In regard to a complaint received during the inspection, there needs to be evidence that appropriate systems have been put in place to ensure that service users are at minimal risk of items going missing from there rooms. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. There are improvements to the environment including décor being made to ensure that service users have an attractive, safe and clean environment to live in, but there are areas that need further progress to be made. EVIDENCE: The care home is a purpose-built premises. Service users spoken to were happy with the accommodation provided. The home is light, airy and centrally Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 21 heated. There was evidence of redecoration work having been completed and further work was in progress. A large, full refuse skip located in the car park of the care home should be emptied. The deputy explained that the home has a maintenance logging system, which informs the full-time maintenance worker about maintenance issues. An inspection of this book found that issues are generally addressed in due course, but that many issues as identified from this inspection were not recorded. The manager spoke of the ongoing work and the maintenance/redecoration plans for the care home. The redecoration work should include seeking advice from appropriate organisations in regard to improving the décor to meet service users varied needs including dementia care needs and those with visual sensory needs. The television on Owl unit needs replacing, as the television could not be adjusted in terms of channel or volume unless poked with a thin implement. Feedback and observations suggested that some of the communal linen provided within the homes might be of poor quality through wear and tear. The registered manager spoke of having recently replaced much of the linen. The microwave ovens in Falcon and Owl unit need replacing. A ceiling light cover in Falcon unit needs cleaning, and a half size brush with a 1-5cm sharp edge instead of a handle needs replacing. The bin in the kitchen there has a broken lid resting on top of it. This is a health and safety hazard that needs addressing. Feedback from service users, and observation, on Falcon unit found that a small number of carpets in bedrooms were difficult to clean effectively. If they cannot be satisfactorily cleaned they must then be replaced. The toilet seat in the shower room in Falcon unit was very wobbly and needs securing before causing an accident. One service user said that the shower room continues to flood despite there being a raised strip under the door. The drainage on the flooring does not work. Additionally, the raised strip prevents easy wheelchair access. The outside door handle of the shower room is loose. The covering seal from floor to skirting board next to toilet needs repair. There are 6 tiles missing around the shower area. Some areas that are not daily cleaned need cleaning. There needs to be a shower curtain, a toilet roll holder, and bin in this room. The extractor fan needs repair. The emergency light that is not working needs repair. The deputy reported that this was in the process of being repaired. The bathroom outside room 7 (Falcon unit) needs some redecoration and repairs. The flaking paintwork, 1 broken tile, a broken and missing ceiling panel at the door, and a lid to the black bin needs replacing or repair. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 22 In Hawk unit there is a broken toilet seat that needs repair, the cover of a light in the communal area is missing and needs replacing, and the radiator that is not working in room 29 needs repair. Overall, all bathrooms and shower rooms are in need of repainting and various repairs. The kitchen in Eagle unit is also shabby and would benefit from being more pleasantly decorated. Feedback from a service user informed the inspector that the water for showering was not always warm. The manager spoke of recent improvements to the hot water system, and reported that the complaint would be investigated. Gloves, soap and hand towels were seen to be accessible. The home was odour free and generally clean. The laundry is located away from food storage and food preparation areas. There have been complaints/concerns in regard to missing laundry items and its cleanliness. The laundry staff member explained the improvements to the laundry system that had recently taken place, and some feedback from visitors and service users confirmed this, but issues of concern remained such as ensuring that all clothes are marked with the service users’ name. The registered person should ensure that the laundry systems continue to improve and are monitored closely. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the varied needs of service users are met by sufficient staff that receive appropriate training. EVIDENCE: The home employs registered general nurses and registered mental health nurses, care staff, two chefs (for the main and Asian kitchens), activity coordinators, a physiotherapist, a receptionist, a maintenance staff member and domestic staff. 15 feedback comment cards recorded that service users felt well cared for, well treated, and enjoyed living in the care home. 5 service users recorded that they sometimes felt well cared for. Service users who kindly spoke with the inspectors were generally positive about the care provided by staff. Staff were observed to interact in a positive and respectful manner with service users Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 24 during the inspection. Visitors who spoke with the inspectors were generally positive about the care provided by staff. The home has continued to review its staffing needs, and there is now an extra care staff member on duty on Hawk unit in the mornings. The deputy manager is working on Owl unit for two shifts per week to assist in the management of the transition period from the unit accommodating older persons to adults with physical disabilities. The manager spoke of having developed the key worker system within the care home, and that system continues to be developed. Pre-inspection information recorded that 35 of staff had completed NVQ care qualifications. The registered manager reported that 50 of the staff would have completed NVQ care courses within a few months. Seven staff are to commence NVQ care courses in November 2006. The registered manager reported that there were plans for some staff to have the opportunity to complete NVQ level 3 in care. Four staff personnel records were inspected. These contained the required information and documentation. One staff member’s record of a satisfactory enhanced Criminal Record Bureau check was not accessible in their personnel file. The manager accessed the appropriate information during the inspection. Staff, records and the manager confirmed that appropriate and varied training was being provided to staff, and that there was a training plan. Staff spoke of receiving comprehensive induction training. Much of the training is ‘in house’ training that is carried out by senior staff. The content of the training is recorded, and includes fire training, infection control, health and safety, basic first aid training, and specialist training such as specialist feeding, nutritional needs, dementia care training, and training in the management of challenging behaviour. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. There is clear leadership, direction and guidance from the manager to ensure that service users’ needs are being met, and that their health and safety is Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 26 promoted and protected, but there needs to be further development in some reporting and recording procedures. EVIDENCE: The registered manager is a level 1 registered general nurse. She has managed the care home for almost a year, and during that time it is evident that she has reviewed a number of procedures and practices and made some improvements to the service. She confirmed that she undertakes regular training to update her skills and competence. She spoke of having commenced the Registered Managers Award qualification. Staff, visitors and service users spoke of the manager being approachable. During the inspection the registered manager demonstrated and communicated a clear sense of direction and leadership. It was evident that she is very motivated and keen to provide a good service, and to continue to instigate improvements in regard to the service provision. The manager has good understanding of the varied and often complex needs of the service user groups within the care home. There are clear lines of accountability within the home and with external management. The manager reported that she ensures that she regularly spends time on the units within the care home. The care home has a quality assurance policy/procedure. The registered manager reported that the care home receives two audits a year of the service including a manager’s assessment audit, and that satisfaction surveys are sent annually to relatives/significant others and supplied to service users. Records confirmed that feedback had recently been obtained from service users about the meals and the activities provided. The manager spoke of the action taken in response to this feedback. Resident and staff meetings are held regularly. There was recorded evidence that policies and procedures are reviewed. Records of required visits to the care home by the provider’s representative are supplied to the Commission. The quality assurance section of the service user guide document should record the Commission for Social Care Inspection, not the National Care Standards Commission, and should be dated. The administrator manages records and the financial accounting of generally small amounts of service users’ monies. Several service users have their finances managed by their relatives. Four service users handle their own financial affairs. Records inspected were up to date and receipts were available for inspection. The registered person should ensure that all the receipts record each item purchased. Individual assessment of service users’ financial needs and action to meet those needs must be recorded. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 27 Recorded pre-inspection information/documentation informed the Commission that the required safety/service checks had been completed and were up to date. The care home has a recorded fire risk assessment, which recorded evidence of having been reviewed. Records confirmed that required fire drills, and weekly fire checks take place. Records and staff confirmed that they received fire training. In Falcon unit the kitchen door was propped open by a brush, and a sitting room door was propped open by a fan. Doors in the care home must not be propped open. If doors need to be open during the day for access an appropriate safe-door mechanism needs to be in place, following advice from the Fire Service. Another door in Falcon unit (with a holding device) did not stay open, and hence wheelchair users had to push through the door. One staff member indicated that the doors also might not shut if the alarm goes off. These doors need to be checked for appropriate responses to the fire alarm, and for their hold-open devices to be working fully so as to ensure their safety and to facilitate the independence and movement of service users. There were observed to be several free standing heaters and fans located in the care home. These need evidence of having been risk-assessed. Several loose electrical leads located near the television in Hawk unit need risk assessment in regard to being a possible trip hazard, and appropriate action taken to minimise any risk. There should be thermometers in the communal areas on the units. The care home has an accident reporting procedure. Accident/incident records were available for inspection. A needle stick injury to a staff member was recorded but there was no evidence that the care home’s policy in regard to this had been followed. A record in regard to a service user who went missing for a short while was not recorded in the accident/incident documentation (though recorded in the service users’ daily records). The registered person must ensure that appropriate reporting (including reporting to the Commission) and recording is carried out following injuries and other issues of serious concern to staff and others. This was discussed with the registered manager. There should be recorded evidence that the registered manager monitors accidents/incidents and that action is taken to minimise risks of these occurring again. Wheelchairs, trolleys, commodes and standing hoists were stored in a variety of places, including in bathrooms, and other communal areas, and bedrooms. The storage of these items needs to be reviewed by the registered person, and there needs to be risk assessment (which is included in the fire risk assessment) in place in regard to the risk of storing these items in communal areas. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 28 Feedback from service users and observation during the inspection indicated that call bells were generally answered promptly. A call bell was tested by the lead inspector during the inspection and was in working order. Fridge/freezer temperatures are monitored. Records confirmed that there were weekly visual checks of the wheelchairs. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 29 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 X 2 X 3 2 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 2 36 X 37 X 38 2 Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 • Requirement There needs to be recorded evidence that service users needs are always fully assessed. • There needs to be evidence that there has been appropriate consultation regarding the assessment with the service user or representative of the service user. • Care plans need to ensure that there is always comprehensive clear recorded staff guidance to meet all service users identified assessed/risk assessment needs i.e. manual handling, nutritional and pressure area care needs. • Assessment and consent needs to be fully documented at all times in regard the use of bedrails. There needs to be recorded evidence that service users (if able) and/or significant others are involved in their care plan, DS0000022924.V296456.R01.S.doc Timescale for action 01/09/06 2 OP7 14, 15 01/09/06 3 OP7 15(c)(d) 01/09/06 Coplands Nursing Home Version 5.2 Page 31 and its development. 4 OP8 12,13 The monitoring systems in 01/09/06 regard to health needs such as fluid balance needs must be developed. • It needs to be clearly documented in the care plan as to whether service users need specialist healthcare in regard to meeting their assessed medical needs. The registered person must 30/06/06 ensure that nurses in the home have further training on the safe administration of medicines. Medicines must be recorded accurately when administered. If not administered the correct endorsement must be used The history of residents allergies must be readily available Dosage changes must be clear, with entries preferably rewritten, and signed and dated Adhesive labels must not be stuck on the MAR as they do not provide a permanent record of administration Medicines must be stored at the correct temperature. Fridges must be maintained between 2 and 8 degrees centigrade and the room temperature below 25 degrees. Clinical rooms must be clean and broken doors repaired. Oxygen must be stored securely with warning signs on doors. Spare cylinders must be checked at least weekly. There needs to be a system in place to ensure that service users have the opportunity to participate in activities on days when the co-ordinaters are not DS0000022924.V296456.R01.S.doc • 5 OP9 13(2) 6 OP9 13(2) 31/05/06 7 8 9 OP9 OP9 OP9 13(2) 13(2) 13(2) 30/06/06 31/05/06 31/05/06 10 OP9 13(2) 30/06/06 11 12 OP9 OP9 13(2) 13(2) 31/05/06 30/05/06 13 OP12 16 01/10/06 Coplands Nursing Home Version 5.2 Page 32 there. 14 OP15 12,14,16 There needs to evidence that service users’ (and others’) cultural needs are being fully met in regard to the provision of meals. • Procedures for improved presentation and provision of meals, particularly breakfast, needs to be in place in the units were it is presently unsatisfactory. There need to be systems for recording verbal ‘concerns’/complaints and evidence that appropriate action is taken in response these. • The registered person needs to ensure that all staff are aware of the appropriate procedures to be followed if there is suspicion or allegation of abuse. • there needs to be evidence that appropriate systems have been put in place to ensure that service users are at minimal risk of items going missing from there rooms. • The television on Owl unit needs replacing. • The microwave ovens in Falcon and Owl unit need replacing. • A ceiling light cover in Falcon unit needs cleaning, and a half size brush with a 1-5cm sharp edge instead of a handle needs replacing. • Carpets on Falcon unit need to be replaced if they are unable to be satisfactorily cleaned. Falcon shower room/toilet: DS0000022924.V296456.R01.S.doc • 01/09/06 15 OP16 22 01/09/06 16 OP18 13(6) 01/09/06 17 OP19 23 01/10/06 18 OP19 23 01/10/06 Page 33 Coplands Nursing Home Version 5.2 19 OP19 23 20 OP35 14,20 The toilet seat in the shower room needs securing. • The issues of flooding, general drainage, and wheelchair access need to be investigated and repaired if needed. • The door handle needs repair. • Covering seal from floor to skirting board needs repair. • 6 tiles missing around the shower area need replacing. • Some areas not daily cleaned, need cleaning. • There needs to be a shower curtain, toilet roll holder and bin in the room. • The extractor fan needs repair. • An emergency light needs repair. • 1 broken tile, the missing 01/10/06 ceiling panel at the door, and a lid to black bin, needs replacing or repair in Falcon unit bathroom opposite room 7. • The floor stain on a shower unit in Owl unit needs removing. • The broken toilet seat in Hawk unit needs repair. • In Hawk unit the cover of a light in the communal area is missing and needs replacing. • The radiator that is not working room 29 Hawk unit needs repair. Individual assessment of service 01/10/06 users’ financial needs and action to meet those needs must be recorded. DS0000022924.V296456.R01.S.doc Version 5.2 Page 34 • Coplands Nursing Home 21 OP38 23 22 OP38 13(4) 23 23 OP38 13(4) 24 OP38 17,37 Doors in the care home must not be propped open. If doors need to be open during the day for access, an appropriate safe-door mechanism needs to be in place, following advice from the Fire Service. • Doors on Falcon unit need to be checked for their safety and appropriate responses to the fire alarm. The storage of wheelchairs, commodes, hoists and trolleys needs to be reviewed by the registered person, and there needs to be risk assessment in place (which is included in the fire risk assessment) in regard to the risk of storing these items in communal areas. • Freestanding fans and heaters need evidence of having been risked assessed. • Loose electrical leads located near the television in Hawk unit need risk assessment in regard to being a possible trip hazard, The registered person must ensure that appropriate reporting (including reporting to the Commission) and recording action is taken following injuries to staff and others. • 01/09/06 01/10/06 01/09/06 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000022924.V296456.R01.S.doc Version 5.2 Page 35 Coplands Nursing Home 1 2 3 4 5 6 7 Standard OP3 OP7 OP8 OP9 OP10 OP10 OP12 Assessment documentation should always be dated and signed by the person completing the record. There should be evidence that the recorded staff guidance in the care plans is always reviewed regularly. The care home should have an accessible recorded gender care policy/procedure. That weekly audits of medication and storage are carried out 8 9 OP12 OP14 10 OP15 11 OP16 12 OP19 Systems in regard to staff monitoring of service users should be in place so service users’ needs are met at all times. The registered person should consider putting in place a payphone on Eagle unit for service users’ use. • It is recommended that there are arrangements in place for care staff to assist activity co-ordinators with activities for service users, so that all service users have the opportunity to participate in activities regularly. • the care home should consider obtaining its own transport vehicle. It should be clearly documented in service users’ care plans their preferred times for bed (with subject to change in line with service users’ preferences). It is recommended that there are systems developed such as a mobile shop, to enable service users to purchase their own toiletries snacks etc when transport and staffing is not available to do this. • Following consultation with service users, snacks and drinks should be provided that reflects their cultural needs and preferences. • There should be more evidence that choice is offered to service users during meals. • There should be evidence that service users have the opportunity to have particular preferred foods on occasions. • Menus should include pictorial format. • The registered person should consider including a summary of the complaints procedure in the service user guide. • It is recommended that there is the opportunity for relatives/significant others to regularly meet with management staff to discuss the service provision and any ‘concerns’ that they may have. • The redecoration work should include seeking advice from appropriate organisations in regard to improving the décor; to meet service users varied needs including dementia care needs and visual DS0000022924.V296456.R01.S.doc Version 5.2 Page 36 Coplands Nursing Home 13 OP19 14 15 OP26 OP33 16 17 18 OP35 OP38 OP38 sensory needs. The maintenance system of reporting and recording should be improved. • Several bathrooms/toilets/shower rooms should be repainted in several units, and the kitchen in Eagle unit would benefit from being more pleasantly decorated. • A large full refuse skip located in the car park of the care home should be emptied. The registered person should ensure that the laundry systems continue to improve and are monitored. In the quality assurance section of the service user guide document/brochure it should record the Commission for Social Care Inspection, not the National Care Standards Commission, and should be dated. The registered person should ensure that all the receipts record each item purchased. There should be thermometers located in the communal areas on the units. There should be recorded evidence that accidents/incidents are monitored by the registered manager and that action is taken to minimise risks of these occurring again • Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow 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. Extracts may not be used or reproduced without the express permission of CSCI. Coplands Nursing Home DS0000022924.V296456.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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