CARE HOMES FOR OLDER PEOPLE
Coppelia House Court Street Moretonhampstead Devon TQ13 8LZ Lead Inspector
Clare Medlock Unannounced Inspection 20th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Coppelia House Address Court Street Moretonhampstead Devon TQ13 8LZ 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) 01647 440729 01647 440884 www.peninsularcarehomes.co.uk Peninsula Care Homes Ltd Vacancy Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: Coppelia House is a Care Home registered to accept 30 residents of either gender who require personal care. The Home is one of five owned by Peninsular Care Homes. Coppelia House is a home that has been extended and adapted over the years to meet the needs of the residents. The home is situated in the rural town of Moretonhampstead, which is close to Dartmoor National Park. Some Rooms have views of Dartmoor and the surrounding countryside. The home is situated within a close distance of the town and local amenities. The town has a post office, coffee shop, shops, pub, doctor’s surgery and small cottage hospital. The Home is arranged over several floors. There are two passenger lifts, which access the main floors. There are additional rooms that are accessed by extra steps, but resident mobility is assessed prior to admission to these rooms. All rooms are meant for single occupancy, however the home does have some large rooms and flats that could be used for those who chose to share. The home has a large dining area and separate lounge area, which overlooks the gardens. The current range of fees are between £287 and £530 per week and do not include hairdressing, chiropody, newspapers and toiletries. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on Wednesday September 20th at 10.30am. It consisted of speaking with residents, relatives, staff, visiting health care Professionals and the manager. A full tour of the building was performed. Care plans, staff files and other records were inspected. Prior to the inspection, the Manager submitted an in depth pre inspection questionnaire. Resident and relative surveys were also returned and used for this inspection. What the service does well:
Staff at Coppelia House provide a very good level of social and Personal care. A dedicated stable, well trained staff group ensure that Residents have all their needs met and ensure residents access a full variety of services. Care planning and delivery of care is very good at the home and links with health care professionals is made when needed. 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, and residents and their families confirmed that this good communication continued after admission. Staff communicate well with Service Users and their families and provide opportunities on a formal and informal basis to ensure their voices are heard and requests acted on. 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. Residents are happy living at the home and feel they are well cared for. Residents say staff are very kind and caring and make sure they have everything they need. The home is well maintained and provides a safe homely place for residents to live and staff to work. The home is well managed. The Manager is supported by the Area Manager and Provider. The Peninsular Care Homes senior Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 6 management team communicate well with the Commission for Social Care Inspection. What has improved since the last inspection?
Despite the many changes in Management there have been many improvements at Coppelia and all the previous Requirements and Recommendations have been met. The Provider has continued to fund improvements to the home. Some carpets had been replaced providing a pleasant safer environment. New chairs have been provided in the lounge and new tablecloths in the dining room also improve the appearance. The staff office has been improved with new flooring and a new chair. Six bedrooms have been refurbished and additional storage provided in the old lift shaft area. The kitchen has been provided with a stainless steel work top and the chef has attended environmental health training in how to manage a safe kitchen. Asbestos has now completely been removed from areas in the home. The Commission for Social Care Commission were informed of this work. Pipe work was being covered to increase energy efficiency and protect residents from risk of scalding. A water cooler had been purchased at the home and this simple change has resulted in more water being drunk by residents. The bathroom has now been completed although residents continue to prefer the deeper assisted bath. A new hoist has also been provided. In the garden, a new rockery had been introduced but was not yet established with plants and was not popular with all residents. The allotment and tomatoes had been well managed and enjoyed by residents. The Care to residents has also improved since the last inspection. The Manager has obtained the new Department of Health publication Infection Control in care homes that has given information on how to protect residents. Care Plans have been improved and the wishes regarding terminal illness and death are now recorded. The Management of medicines has improved with a further two staff being trained in the management of medicines. A new policy has been written which explains how staff can manage the receipt, administration, storage and return of medicines at the home.
Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 7 Policies at the home have been up dated and help staff in dealing with unusual or difficult situations. Residents are enjoying the food a little more and have their weight recorded regularly. This helps staff spot when residents are at risk of loosing or gaining too much weight. The Management has also changed at the home. Residents, staff and healthcare professionals have welcomed the return of the present Manager. Recruitment Practices have improved at the home. All staff files are complete to show staff have the correct checks performed before working. The Manager also has a checklist to make sure this happens. Training at the home has improved. Staff have received training in adult protection awareness, fire safety, medicine training and NVQ qualifications. This means that staff will work in a more practical safe way and their knowledge will be up to date. As an organisation the home and other homes have achieved the investor in people award. What they could do better:
The Manager and supporting staff have worked hard to meet the previous Requirements and Recommendations. She now needs to have a period of settling in where residents, staff, relatives and health care professionals can become confident that she will provide continuity for the home which will result in improved communication and improved standard of Care. Staff at the home must now work to make sure their records reflect the care that has been given and show that risk assessments are repeated to monitor slight changes. Staff at the home should ensure they all knock on resident’s doors and wait for a reply before entering. The Manager should continue with the planned improvements to the home and should ensure all staff, including night staff, complete an induction within the first few weeks of work. The Training programme should continue and the staff that repeatedly do not attend the sessions should be addressed. The Provider should ensure the garden is tidied to return it to its previous standard.
Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 8 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. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 1,2,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Residents and their families are given enough information to decide whether Coppelia is the right place for them to be. The thorough assessment of prospective residents ensures staff at the home are able to meet their needs. EVIDENCE: A Statement of Purpose and Service User Guide was produced for this inspection. Both documents had been updated to include the name and details of the Manager who had been in post for two months. Both documents were inspected and included necessary up to date information to enable Residents to decide whether the home is the right place for them to be. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 11 All Residents are issued with a contract. A sample of these contracts was seen and contained the correct information. Residents spoken to say they and their relatives made the final decision to come to the. One resident said her daughter had looked at many homes and decided Coppelia House was the right place for them. Residents spoken to said the Manager visited them before they were admitted which was lovely and meant they had a familiar face when they came to the home. Care Plans confirmed that the Manager performs a thorough check on residents to make sure staff at the home can meet their needs and know where to access specific help and advice. The Manager confirmed that if they had any resident with physical, social or cultural differences they would find out as much information prior to the admission. The Manager stated that this would probably be done through the internet and asking healthcare professionals. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The clear and consistent care planning system means that the health and social needs of Residents are fully planned. Staff communicate well with the multi disciplinary team. There is an ethos within the home that most staff promote the privacy and dignity of Residents. EVIDENCE: All residents seen on the day of inspection appeared well cared for. Residents had call bells within reach. Residents were seen to have clean eyes, glasses, nails and teeth, and were dressed in their own clothes. Residents who wore glasses had them on and footwear appeared appropriate. Residents stated that they felt very well cared for. Residents said the GP was called when needed and ‘you only have to ask and it’s done’ Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 13 Three Care Plans were inspected on this occasion, which clearly demonstrated that Residents are assessed before admission. This information is then transferred onto a new care plan, which lists all their needs, and makes sure staff are aware of all aspects of the care. This system of Care Plans has been improved since the last inspection. The newly changed care plans were inspected and were written in a way that was easy to read and follow. All care plans were up to date, but did not reflect the detailed care that was actually given. Risk assessments for skin care, nutrition, continence, risk of falls and use of bed rails were seen in care plans and had been regularly reviewed but not repeated. It was suggested that by regularly repeating the assessments would pick up small changes. Care Plans showed that staff access a range of health care services for the residents. These services included out patient appointments, visits by the GP, District nurse, speech and language therapist, physiotherapist. Continence nurse specialists and other nurse practitioners are also consulted when needed. Observation confirmed that staff within the home access the services of General Practitioners, but residents also access the General Practitioner directly if they prefer. The Manager demonstrated a detailed knowledge of residents at the home. Residents said they receive their medicines on time and staff arrange for the doctor to visit whenever was needed. Residents also said they felt well cared for and did not have to wait too long for their bell to be answered. Residents said they had to wait for a bath but this was their choice, as they preferred the deeper bath, which was worth waiting for. Residents said the majority of staff knock on the door before entering but sometimes this could be forgotten. The inspector witnessed this and the member of staff informed of the error. All residents said their privacy was protected when having a bath or when personal care was being given. The homes medication administration system is a pre packed blister pack system that the local pharmacy delivers with some additional boxed or liquid medicines. The storage area of the medicines were, clean, tidy and secure and the systems for the collection and disposal of medicines were well managed. The recording of medication was well completed. Four Resident questionnaires were received regarding this service. All stated that residents feel they always receive the care and medical support they need. Two relative questionnaires were received. These stated that they are always kept up to date with changes in care and consulted about plans of care. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 14 A Visiting GP stated that care has been OK at the home but communication has been poor with all the changes of manager. The GP knew the Manager and stated that he felt confident that the return of the Manager would improve the care, communication and service at Coppelia. Residents spoken to say the staff at Coppelia have been marvellous but that it was excellent to have the Manager back. A folder within the office show past and present resident and relative thank you cards and letters. These letters thank staff for their care and dedication in the care that is given throughout their stay and in the final days. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Residents have choice and control over their lives whilst living at the home and enjoy the meals that are provided. Social activities are based on the individual preferences of the Residents. EVIDENCE: Observation of the visitor’s book confirmed that friends and family have access to the home at any reasonable time. Discussion with relatives confirmed relatives are able to visit their families whenever they chose. A tour of the home confirmed that Residents rooms are personalised by bringing in personal possessions with them to the home. Residents spoken to said they are able to go out for lunch with family and friends. Residents spoken to say they always receive post unopened and are able to make and receive telephone calls in private. Residents said they had routines for their care but these could be changed if requested. Discussion with the Manager and observation confirmed that the home have an activity co coordinator who has a mixed activities programme. Residents
Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 16 spoken to said they were able to join in with these activities if they chose. Staff said these activities are varied. Observation confirmed the home were involved in the recent carnival and won the best window display and flower display. During the inspection an entertainer was present at the home. Other activities advertised included bingo, clothes shows, musical exercise, film afternoons, hairdressers, Holy Communion, the Sunday sherry event, pantomime visits, 1:1 shopping visits, and chiropodist. A recent fete day had also been held with monies raised going to the Devon Air Ambulance. All residents and relatives spoken to said the food was better than it had been in recent months. Residents said there was enough to eat. A rota of menus was produced pre inspection. On the day of inspection residents were served a roast dinner followed by angel delight. Staff have also introduced a nutritional screening tool and started weighing residents regularly, which identifies those residents of being at risk of loosing or gaining weight. There has been a new chef at the home who explained about the environmental health ‘Safer food better business programme’ which she was following. During the inspection care staff were heard offering residents a choice of meals. Residents spoken to said they were always offered a drink and biscuits at coffee time, and cake with the afternoon drink. Discussion with the Manager confirmed that staff have access to food and drink at all times of the day or night just in case residents were hungry. Staff have a food likes and dislikes list and a birthday list. Staff said all residents get flowers and a homemade birthday cake on their birthday. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The recent training in adult protection awareness is beginning to protect Residents and will continue as it is completed. Residents feel able to complain knowing the manager will act on them appropriately. EVIDENCE: Residents spoken to said they felt safe at the home and that staff were kind and gentle. All resident and relative questionnaires stated that no complaints have needed to be made but they knew how to complain. Residents said they have not needed to complain because things get sorted out before they become problems. Residents spoken to said that now the Manager is back and has the Managers positions life will only get better. The Manager stated that she has received one complaint. Records showed that the Manager was dealing with this appropriately. The Commission for Social Care Commission have not received any complaints since the return of the new manager. Other concerns identified have been dealt with effectively by the area manager. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 18 Staff at the home spoken to said they have never had to complain but go to the Manager with small issues, which get sorted out immediately. Staff also aid it was good because the Manager had worked as a carer and knew the problems that happened. Discussion with the Manager confirmed that the majority of staff have had their POVA (Protection of Vulnerable Adult) training but that a few named members of staff had been bad at attending this training. It was suggested that the homes disciplinary procedure may need to be used if staff continually miss mandatory training sessions. The home have local Devon County Council Alerter Guide policies as well as up to date policies and procedures which include whistle blowing which ensure staff are protected if they report abuse. Discussion with the Manager confirmed she would have no hesitation reporting allegations of abuse. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 19 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 the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Coppelia House is an adapted house, which provides a safe comfortable home in which Residents are able to stay as independent as possible. The home has a good standard of décor, furnishings and fittings, which provide a comfortable pleasing environment for residents to live in. EVIDENCE: Coppelia House is a Care Home, which has adaptations and equipment to ensure Residents needs, are fully met. There is a choice of bathing facilities, both assisted and unassisted, and there are a number of toilets strategically placed around the home. There are also well placed storage cupboards throughout the home. Communal areas provided a variety of furnishings, which promoted a homely feel. A tour of the building confirmed that the home employ a maintenance man who carries out routine and ad hoc repairs.
Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 20 A tour of the building confirmed that Coppelia House was clean, tidy and free from offensive odours on the day of inspection. Residents stated that it was always like this and that staff worked very hard at the home. A tour of the building confirmed that the Provider continues to fund improvements to the home. Some carpets had been replaced providing a more pleasant safer environment. New chairs have been provided in the lounge and new tablecloths in the dining room also improve the appearance. The duty room has been improved with the new flooring and a chair has been replaced. Six bedrooms have been refurbished and additional storage provided in the old lift shaft area. The kitchen has been provided with a stainless steel wok top. During the inspection routine and repair work was being carried out on the dishwasher. Asbestos has now completely been removed from areas in the home. The Commission for Social Care Commission were informed of this work. 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 made. All radiators seen were covered and all first floor windows checked had been fitted with restrictors. Pipe work was being covered to increase energy efficiency and protect residents from risk of scalding. A water cooler had been purchased at the home and discussion with the Manager confirmed that this simple change has resulted in more water being drunk by residents. The bathroom has now been completed although residents continue to prefer the deeper assisted bath. A new hoist has also been provided. The Manager has obtained the new Department of Health publication Infection Control in care homes. Staff have received infection control training. The Manager stated that new washing machines have been ordered and a contractor manages waste at the home. The garden was looking a little neglected. A new rockery had been introduced but was not yet established with plants. This was not popular with all residents. The allotment and tomatoes had been well managed and enjoyed by residents. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 21 Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The improved recruitment procedure and staff induction ensure a suitably selected team cares for residents. EVIDENCE: Two staff files were inspected on this visit. All files contained all information required to show that all staff have had the necessary checks performed. The Manager said that she has a checklist to make sure all information is required. The Manager confirmed that all staff are issued with a contract. Written induction records are made, however staff files confirmed night staff had not received the same induction as day staff. This should be addressed. Records confirmed that the induction was thorough and included information about emergency procedures. The Manager and Provider have worked very hard since the last inspection to ensure training programmes have been supported. Two staff now have completed a minimum of NVQ 2 training, 3 staff are doing NVQ 3. This means that at least 50 of staff have NVQ training. In addition to this 2 staff are doing NVQ 4. The Peninsular organisation has also achieved Investor In people despite the unsettled management at the home.
Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 23 Off Duty confirmed that staffing is more stable at the home than in recent times. The home have a stable core group of staff. The Manager has tried to keep Staffing levels to 5 carers in the morning plus the manager, 3 or 4 in the afternoon plus the manager, 3 carers in the evening and 2 carers at night. In addition to this additional cleaning and catering staff are employed. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The manager is supported well by staff within the home with all staff demonstrating an awareness of their new roles and responsibilities. The home is generally well managed and provides a safe place to live. Training at the home is adequate and helps protect residents, staff and the Provider from risk. EVIDENCE: The major concern at Coppelia over the last four years has been the unstable management at the home. The home also went through the change from being a nursing to residential only care home. Since the last inspection the home has had two other Managers who have also left. In the last three months the Provider and Area Manager have been keeping the Commission for Social Care Commission up to date with events at the home.
Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 25 At the last inspection, the Team Leader had been in an active supporting role to the Manager and provided much evidence for the inspection providing necessary knowledge regarding the running of the home and the residents. Since this time this Team Leader had worked at another home for Management experience and started the NVQ 4 course. The Provider and Area Manager have since recognised the experience of the Team Leader and promoted her to become Manager. Records and discussion with residents confirmed this decision has been welcomed by residents and their families. Discussion with the Manager confirmed she has completed 5 of the 8 units of her NVQ 4 and was enjoying the course. She has been in post for 2 months and would submit her application with the Commission for Social Care Commission when this has been completed. At the inspection, The Manager was extremely cooperative, polite and knowledgeable. All standards were covered for the benefit of the Manager on her first inspection. The Manager was able to demonstrate different types of evidence for the inspection. Throughout the inspection comments from Health care professionals. Residents, staff and relatives have been extremely complimentary about the Manager. Resident meeting notes recorded that the Manager was welcomed to the home by a resident and this resulted in a round of applause from other residents at the meeting. Staff said the Manager was very approachable but knew what standard of care she expected. Residents said life could return to normal now the manager was back. A visiting GP stated that communication had been poor but felt confident that this would improve with the return of the Manager. The Manager stated that she has support from the Providers and that she is able to call on them for advice as and when it is required. Discussion and records confirmed that staff receive regular supervision as part of the management structure and as a formal process. Since the last inspection the Manager has worked very hard to perform a quality assurance survey. This information has not yet been collated The Home is managed very well. The Manager employs an administrator who is involved in the day-to-day running of the home. Together they have improved some records. ‘Pocket monies’ were inspected on this occasion and found to be well managed. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 26 Discussion with Residents and Relatives confirmed that the home do not manage their financial affairs. The Residents, their families or a solicitor does this. Up to Date Service Records were seen in respect of the prevention of legionella, fire safety, lift, hoist maintenance, gas and electricity checks, and waste management. Generally the records seen within the home were well maintained. First Aid boxes were present at the home Accident books allow for the reporting of dangerous incidents to RIDDOR and allow follow up and action. All records seen were secure and stored in a safe manner. Staff have received induction and training on a range of health and safety related topics. Further training has been booked for the near future to ensure staff are regularly updated. Policies and procedures are in place on health and safety subjects. Risk assessments are in place for the environment. Training records confirmed the majority of staff had updated on mandatory training. Discussion with the Manager confirmed one or two staff had not attended training. The Manager was informed that this was mandatory and she should follow the homes disciplinary procedure if staff repeatedly did not attend training provided by the home. Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP7 OP7 OP10 OP19 OP30 OP38 Good Practice Recommendations The Manager should ensure staff write care plans and notes in a way that reflects the care that is given The Manager should repeat the assessments when they are reviewed to show any minor changes in conditions The Manager should ensure all staff knock before entering a Service User bedroom The Manager should ensure the garden is kept tidy The Manager should ensure all staff (including night staff) have an induction when starting at the home. The Manager should ensure all staff attend training that is arranged and provided. The Manager should consider using the appropriate process if necessary for those staff that repeatedly do not attend Coppelia House DS0000040423.V300017.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office 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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