CARE HOMES FOR OLDER PEOPLE
Coppelia House Court Street Moretonhampstead Devon TQ13 8LZ Lead Inspector
Clare Medlock Announced 20 April 2005
th 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. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Coppelia House Address Court Street, Moretonhampstead, Devon, TQ13 8LZ 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) 01647 440729 01647 440884 Robin George Cannon Position vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: Old age not falling within any other catergory (30) Date of last inspection 14 September 2005 Brief Description of the Service: Coppelia House is a Care Home registered to accept 30 residents who require personal care. The Home is one of five Care Homes owned by Peninsular Care Homes. Coppelia House is a home which has been extended and adapted over the years to meet the needs of the Residents. The home is situated in the rural small town of Moretonhampstead, which is close to Dartmoor National Park. Many Rooms have views of Dartmoor and the surrounding country side. The home is situated within the town and is within close proximity to the town and local amenities. These include a post office, pub, shops and Doctors surgery. Moretonhampstead also has a local cottage hospital where some NHS services are accessed. Coppelia House have recently gone through changes which means they no longer provide Nursing Services. Nursing is accessed through the district nurse team. The home is arranged over several levels. There is a lift which accesses the main floors. Some rooms are accessed by one or two extra steps. Residents mobility is assessed prior to moving into these rooms. All rooms are for single occupancy, however the home have some larger rooms and flats which would be suitable for those who chose to share. The home has a large dining room and large lounge area which overlooks the well maintained garden. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on Wednesday 20th April 2005 between 09.30 and 4.30pm. This inspection consisted of speaking with Service Users (Who requested to be called residents), family, staff and management within the home. A full tour of the building was conducted. Care records, staff files, policies and procedures and other records were inspected. Seven residents, one relative and six staff were spoken to. Three Relative questionnaires regarding the service were received and five Service User questionnaires. Coppelia House have been subject to many changes over the past two years, including change of ownership and three changes of management. What the service does well:
The staff at Coppelia provide a very good level of Personal care. A dedicated staff group ensure that Residents have all their needs met and ensure residents access a full variety of services. The routines within the home are flexible depending on the choice of the residents. Residents and their families are given information and opportunities to visit the home prior to making a decision to move into the home. Residents spoken to were happy living at the home and praised the care staff within the home. The staff group are keen to maintain the high standard of care despite the many changes that have occurred within the home. Staff have a good understanding of the needs of Residents and importance of choice and respect. The staff team organise the activities programme and encourage residents to maintain contact with friends, family and the local community. The home is well maintained and decorated to a high standard. The home is equipped to ensure Residents are helped to maintain as much independence as possible. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better:
Coppelia House is not well managed on a day to day basis. This needs to be addressed as a matter of urgency. The lack of clear direction and leadership by the Manager within the home and out of date policies is affecting many areas of life for the residents and have the potential to place Residents at risk. The Manager and all Staff must know what to do if abuse is suspected within the home- training needs to be completed as a matter of urgency. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 7 Residents need to be assessed properly before coming to the home, this will make sure that Coppelia House is the right place for them to be. This will make sure staff feel confident that they will be able to care for new residents. This is especially important following the change from being a nursing home. The medication system must be managed properly by the Manager. This will make sure Residents receive the right medication, and make sure that staff are aware of what they need to do to make sure residents don’t run out of medicines. Feedback regarding the food needs to be obtained from all residents, relatives and staff to make sure residents are happy with the standard of food they receive. Changes are needed to make sure residents and relatives are able to raise their concerns and feel confident that they will be acted upon. Making sure residents and their families are aware of how to complain and organising resident and relative meetings would help this. In order to safeguard residents, minor improvements in how personal money is managed should be introduced. Training must be completed to ensure there is a qualified first aider on duty at all times. Staff also need to know how to provide care in a safe way and within a safe environment-training for all staff in manual handling, fire safety and infection control must be completed and up to date. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 8 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 Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 9 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) 1,2,3,4 and 5. Residents are not thoroughly assessed prior to admission which means staff do not have the information to decide if they can care for the individual before they move. This places the Resident, other residents and staff at risk. Residents and their families are given useful information and are made to feel welcome prior to and after moving in. Residents are cared for by a skilled team of care staff. EVIDENCE: Coppelia House have a Service User Guide and Statement of Purpose which was written by the previous manager to reflect the changes from Coppelia no longer providing Nursing Care. Both Documents contained all the necessary information. Inspection of two Resident files confirmed that each resident is issued with a contract and terms of residency. Both documents were signed and contained all information required.
Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 10 Discussion with the Manager and inspection of Care Plans confirmed that the home have an assessment tool for use prior to admission. Inspection of the three most recently admitted Residents confirmed that none of the three tools seen had been completed with basic information being omitted, which means the resident being admitted, existing residents and staff are at risk. Coppelia House has an established team of care staff who have been prepared to solely care for residents. Records, Discussion with the Manager, Area Manager and senior carer confirmed that staff have the skills and knowledge to care for the residents within their care. Examples given of extra training included: the administration of medicines, MRSA, and wound care. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 11 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) 7,8,9,10 and 11 The general and specific care needs of the residents are well met by a dedicated established team of staff who promote the privacy and dignity of residents. The system for recording residents needs and recording how they will be and have been met is inadequate and does not reflect the level of care that is given. Whilst the administration and recording of medications is good, the management of the medication system is poor which potentially places residents at risk. EVIDENCE: All Residents seen on the day of inspection appeared well cared for, with the finer details of care attended to. This included clean shoes, new hairstyles and nail care. Residents who were being cared for in bed appeared warm, comfortable and pain free. All Residents spoken to stated that they felt well cared for. All residents stated that staff were kind and caring. All of the questionnaires stated that resident/relatives felt they were well cared for. All of the questionnaires stated that Resident felt staff treat them well and
Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 12 with respect. One relative questionnaire stated that their relative had been living at Coppelia for two years and that they have received a consistently high standard of care during that time. Observation and discussion with the Manager, Area manager and senior carer confirmed that the poor management of care plans had been identified prior to the inspection and the system was being changed. On the day of inspection some care plans had been changed. Discussion with Residents confirmed that they were unaware this change was occurring. Observation, discussion with staff and the home’s diary confirmed specialist services such as district nurses, speech therapist and dieticians are accessed by staff. Residents confirmed this was normal practice and that staff access the General Practitioner when needed. Observation confirmed that the Manager relied heavily on the senior carer regarding the management and subject of medications despite the manager being a registered nurse. Discussion and observation confirmed that the home do not have a policy on how staff should manage the medication system. Observation confirmed that there was no record of receipts of medication. A tour of the building confirmed prescribed products were being used for residents that they were not prescribed for. Residents spoken to confirmed that the senior care staff give out the medicines on time and contact the General Practitioner about any changes. Residents said that staff are very kind, sensitive and respectful. Observation confirmed that staff knock on Residents doors prior to entering and prevent entry when care was being given to protect their privacy. Residents said this was normal practice. Residents spoken to said that generally they do not have to wait long for the call bell. Observation confirmed that Residents are able to receive visitors in private and use the telephone in private. Records, discussion with the Manager, senior carer and staff confirmed that the health care needs of residents who are dying are well recorded. However evidence that their social and spiritual needs are met was not available. Staff gave assurances that this care was given but not necessarily recorded. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 13 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) 12,13,14 and 15. Social activities are creative, well managed and varied. Residents have choice and control over their lives whilst living at the home. Whilst the variety of the menu is good, the standard of the food provided is not always praised by all Residents, relatives and staff. EVIDENCE: Residents and staff confirmed that forthcoming activities are announced at the weekly Sunday sherry party and on a daily basis. Residents stated that this included: craft sessions, bingo, entertainers, quizzes and puzzles, singers, and church services. Discussion with the area manager confirmed that future events to be organised include slide shows and new singers. Residents stated that they are able to join in or opt out of these activities as they chose. Residents stated that they also provide their own entertainment in the form of audio tapes, walks out into the garden and local town, and visits by family and friends. Four of the five resident comment cards stated they felt there were enough activities. A tour of the building confirmed a photograph board which demonstrated activities which included a visit from a local school, sing a long sessions and gardening. Forthcoming activities were also displayed on this board.
Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 14 All residents spoken to felt they had enough choice whilst living at the home. Residents stated staff will help them with what they choose to do. All relative questionnaires and discussion with relatives confirmed that staff welcome visitors to the home. Discussion with the Manager and Deputy Manager confirmed the home have a four week menu plan which appeared to be nutritious and well balanced. A tour of the kitchen confirmed there was plenty of fresh fruit and vegetables and that the management of the kitchen was good. Feedback regarding the food was mixed. Some Residents said the food was very good. One Resident said it was only good because of the inspection. Another resident stated that it was generally poor but good on that day. One of the resident comment cards stated that the food was not good. One Relative questionnaire stated that the standard of food had fallen since November 2004. Some staff stated that feedback was difficult to give to the chef. One resident stated that their specific diet was catered for and feedback to the chef was easy to do. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 15 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) 16,17 and 18 The complaints process within the home is poorly managed and does not ensure Resident’s views are listened to and acted upon. The Manager has a poor understanding of the action needed which may prevent residents using their right to vote. The Manager’s poor knowledge of adult protection issues, documents and what to do if abuse is suspected is placing Residents at risk and make staff vulnerable. The training of adult protection procedures is incomplete. These issues are placing Residents at risk. EVIDENCE: A complaints procedure is displayed within the hall and within the Statement of Purpose and Service User Guide. All documents contain timescales and information on how to contact the Commission for Social Care Inspection. Feedback cards confirmed that not all Relatives and Residents know about this procedure and not all residents are clear who to go to with a complaint. Residents spoken to said they would go to the senior carer or area manager. One relative comment card stated that if minor issues are mentioned they are not done and that staff do not respond in a positive way. Discussion with the Manager confirmed that she has not maintained a complaints register. Discussion with residents revealed that they had not been told how the forthcoming elections were going to be organised. Discussion with the Manager confirmed that this process had not been organised yet. The Area Manager
Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 16 stated that the administrator would ensure all residents would be able to vote and that usual processes would be followed to ensure this could happen. Discussion with the Manager revealed that she did not know the whereabouts of the Devon County Council Alerters Guide. When asked, the Manager was unaware for the correct reporting procedures should staff, residents or relatives report abuse. Records confirmed that adult protection training is incomplete. Staff spoken to within the home said they would report any abuse to the senior carer or the area manager. The staff spoken to at the inspection knew of the Devon County Council Alerters Guide. All residents spoken to said staff were kind within the home and that they felt safe living at the home. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 17 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) 19,20,21,22,23,24,25 and 26. The standard of the environment with Coppelia is good, providing residents with a safe attractive homely place to live. EVIDENCE: A tour of the building confirmed that Coppelia House was clean, tidy and free from offensive odours on the day of inspection. The home is well maintained by a full time maintenance man who performs regular and ad hoc repairs. Communal areas provided a variety of furnishings which promoted a homely feel. A tour of the building confirmed that residents are encouraged to bring personal items with them to the home. Records confirmed that a list of these possessions is not always made which puts the manager and residents at risk should items go missing. A tour of the building confirmed that the décor within the home is good, providing residents with a homely place to live. The home has been adapted to encourage the independence of Residents and provide safe working
Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 18 environments for staff. Previous requirements had been acted upon: All radiators seen were covered and all first floor windows checked had been fitted with restrictors. Records were seen for the prevention of legionella. A tour of the building confirmed that the home have a well equipped laundry, with washing machines that have cycles to ensure foul linen is washed in a way that prevents infection to other Residents and staff. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 19 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) 27,28,29 and 30. There is a stable staff group at the home are able to met the needs of the residents. The improved staff files, recruitment procedures and induction process now safeguard resident safety by ensuring staff have had necessary checks and references performed. EVIDENCE: Off Duty records confirm that the Manager and senior carer provide a stable staff group, with the right levels of staff, that ensure Residents needs are met and that the home is well maintained and a safe and comfortable place to live. Residents stated that they feel there are enough staff generally but sometimes holidays and sickness affect this. Two of the three relative questionnaires stated that they thought there were enough staff. One relative spoken to said she thought there were generally enough staff and that her mother always looked well cared for. Records confirmed that staff are working towards ensuring at least 50 of care staff have NVQ training. On the day of inspection one care staff was going to collect his NVQ certificate. Records and discussion confirmed that remaining staff are either doing NVQ training or are enrolled to start. Examination of staff files confirmed that all staff have the right checks and references obtained to ensure residents safety is protected. This has improved since the last inspection. Staff files contained evidence that staff have a formal
Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 20 induction process to ensure they are aware of their role and how to keep residents safe. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 21 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) 31,32,33,35,36,37 and 38. The day to day management of Coppelia House is poor and relies heavily on care staff within the home. This poor leadership is not in the best interests of the residents, staff and service as a whole. EVIDENCE: Throughout the inspection the Manager regularly asked the senior carer and area manager for guidance and information which should be known by a manager. Discussion with staff confirmed that lines of leadership are unclear and most advice is either obtained from the senior carer or area manager. Four Residents knew the name of the Manager and stated that she was kind and approachable. Two residents spoken to did not know who the manager was. One Resident stated that she had never met her and residents stated they would go to the area manager or senior carer to sort out any issues.
Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 22 Staff spoken to stated that the manager does not give a clear sense of direction. The Manager stated that there have been no staff meetings or staff supervision for a period of six months. Staff spoken to confirmed this. Residents and relatives spoken to confirmed that their views had not been obtained regarding the service and relative and resident meetings had not been held for a long time. Records kept by the manager were generally poor which places residents at risk. Other records seen within the home appeared generally secure and up to date. Accident books were completed correctly. Policies and procedures seen had not been updated since the last manager which could result in residents not getting up to date care or services. Residents spoken to confirmed they manage their own finances where possible. Relatives confirmed that where this is not possible families and solicitors handle financial affairs. Discussion with the Manager revealed that she is unaware of how to access independent advocacy services, despite the home displaying age concern information leaflets. The area Manager stated that it is the policy of Penninsular not to act as agent or appointee for residents. Residents spoken to confirmed that the administrator holds a small amount of petty cash for events such as the hairdresser and chiropodist and that relatives deposit money. Inspection of these records revealed two inaccurate balances. Both amounts were more than the balance stated but demonstrate the need for two signatures to be obtained for all deposits and withdrawals. Separate receipts were not issued by the hairdresser which potentially cause problems should residents, relatives or solicitors wishing to see proof of spending. Training records could not confirm whether all staff have received all mandatory training which potentially could place residents and staff at risk of living and working within an unsafe environment. There is not always a first aider on duty at all times. Moving and handling training is not all up to date, not all staff have received fire training or food hygiene training. Systems and contracts are in place to ensure the home and equipment is safe. Records to confirm that the lifts are serviced. Fire equipment has been maintained, measures for the prevention of legionella, and electrical testing were available. On the day of inspection service engineers were at the home checking gas equipment. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 1 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 2 1 1 1 1 x 1 1 1 1 Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 24 No 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 OP 3 Regulation 14 Requirement The Manager must ensure: 1.Residents are fully assessed prior to moving into the home. 2. Any documents used for this assessment are completed. The Manager must ensure: 1. All Care Plans are complete, up to date and reviewed and 2. Involve the residents and their families in this process. The Manager must make sure the medication system is maintained which includes: 1. Keeping a record of medications coming into the home 2. writing and maintaining a policy of how staff can manage the medication system in the absence of the senior carer 3.Ensuring only items prescribed for residents are used on those residents. The Manager must obtain feedback from all Residents and relatives regarding the food provided. The Manager must maintain a complaints register to demonstrate what action is taken following a complaint Timescale for action 11/10/05 2. OP8 15 (1,2) 11/10/05 3. OP9 13(2) 11/10/05 4. OP9 12(3) 16(2i) 22 11/10/05 5. OP16 11/10/05 Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 25 6. OP18 13(6) 7. OP31 9(1) 8. OP32 12(2,3) 21 24 (1) 9. OP33 10. OP35 13(6) 16(2l) 11. 12. OP36 OP37 18(2) 16(2d,l) 13. OP38 18(ci) The Manager must ensure: 1.She is aware of the correct reporting procedures should abuse be suspected. 2. All staff adult protection training 3. Staff are aware of the correct reporting procedures and know who to tell if they suspect abuse The Provider must ensure the Manager has the skills and knowledge to manage a care home. The Manager must ensure residents, relatives and staff are able to affect the way the service is provided The Manager must establish and maintain a system for reviewing and improving care within the home The Manager must ensure Residents personal allowances are safeguarded by: 1. Obtaining two signatures as a deposit or withdrawal is made 2. Obtaining separate reciepts for each transaction made (Hairdressing) The Manager must ensure staff recieve clinical supervison. The Manager must ensure a record of possessions bought into the home is made and maintained for all Residents. The Manager must ensure all staff mandatory training in respect of fire, manual handling, food hygeine,infection control and first aid. 11/10/05 11/10/05 11/10/05 11/02/06 11/10/05 11/02/06 11/10/05 11/10/05 Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP11 OP16 OP32 OP37 Good Practice Recommendations The Manager should make sure that the social and spiritual needs are recorded for residents who are dying. The Manager should ensure all residents and relatives are aware of how to complain. The Manager should have a job description that clearly identifies his roles and responsibilities. The Manager should review policies and procedures within the home. Coppelia House D54-D07 S40423 Coppelia House V210897 200405 Stage 4.doc Version 1.20 Page 27 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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