Inspection on 23/05/05 for Coppermill Care Centre

This inspection was carried out on 23rd May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Coppermill Care Centre 05/10/06

Coppermill Care Centre 24/10/05

Coppermill Care Centre 23/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Coppermill Care Complex 10 Canal Way Off Summerhouse Lane Harefield, Middlesex UB9 6HS Lead Inspector Robert Bond Unannounced 23rd May 2005 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. Coppermill Care Complex Version 1.10 Page 3 SERVICE INFORMATION Name of service Coppermill Care Complex Address 10 Canal Way, Off Summerhouse Lane, Harefield, Middlesex UB9 6HS 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) 01895 820130 01895 820149 Coppermill Care Limited Johan Neeskens Care Home 52 Category(ies) of Dementia - over 65 years of age (32), Old age registration, with number not falling within any other category (20) of places Coppermill Care Complex Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23 and 24 September 2004 Brief Description of the Service: Coppermill Care Complex is a 52 bed purpose built care home that is registered for 20 older people and for 32 with a diagnosis of dementia. It is owned by Coppermill Care Ltd, director Mr Shah. The building was opened in 2000 and is on three floors, with a lift between them. The first and second storeys comprise the dementia unit. The home is adjacent to a development of private housing and small business units on a former industrial site alongside the Grand Union canal. The home is fully accessible throughout for wheelchair users, with wide corridors and large single bedrooms that are all en-suite. An enclosed garden is at the rear. Limited parking is available at the front of the building. The area is isolated from shops and services, the nearest being a mile away in Harefield. There is no public bus service nearby but the home has a company car that is available to take residents out and to collect relatives from Harefield village. Two activity co-ordinators are employed in the home. Coppermill Care Complex Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection but the Inspector was made very welcome and was assisted by all members of staff. The management and staff are thanked for their helpful assistance. The inspection took place over one full day and it included a tour of the home, speaking to management, staff and residents, observing the care provided and examining records. Questionnaires were subsequently sent to a sample of relatives. At the last inspection 19 requirements and 5 recommendations were made. All but 4 of these have been met. A further 13 requirements and 2 recommendations have been made in this report. On the day of the inspection, there were four vacant places, all in the dementia unit. All staff posts were filled and no agency staff were being used. The Registered Manager has achieved a great deal in the nine months since the last inspection for which he is commended. Further improvements are planned, but there is still a lot to achieve as of 32 Standards inspected against, only 13 were fully met, 15 were almost met and a further 4 were not met. What the service does well: What has improved since the last inspection? Record keeping such as assessment documents and care plans have improved. There is now an activity co-ordinator for the ground floor. The deputy manager who left has been replaced by two team managers, one for the ground floor and one for the dementia unit. They will be accountable for the services in their respective areas. A quality assurance scheme has been introduced, the complaints procedure improved, Council adult protection policies obtained, more staff training provided, a shower installed on the first floor, lighting has been improved in the foyers of the dementia unit, a maintenance plan has been devised, and formal recorded supervision of staff has commenced. All these aspects have improved outcomes for service users. Coppermill Care Complex Version 1.10 Page 6 What they could do better: 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. Coppermill Care Complex Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Coppermill Care Complex Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2,and 4 In order to obtain the intended outcomes for service users, the information available to them and their relatives requires some further work. New service users are appropriately assessed. EVIDENCE: The home’s Statement of Purpose and ‘’Service Users’ Guide’ need to be updated, in particular to refer to Respite Care which the home makes available if a long term vacancy exists. Service users who are funded by a Local Authority are required to have an individualised statement of the terms and conditions that apply, in addition to the generalised Service Users’ Guide. Details of what is required are given in National Minimum Standard 2, Care Homes for Older People. The Registered Manager has devised a new assessment document for potential service users who are self-funding. A completed multi-disciplinary assessment was seen on a service user who had been referred by Hillingdon Council. Coppermill Care Complex Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9, 10, and 11 In order to improve outcomes for service users, care planning must be further developed, to include ‘Dying and Death’ as per NMS 11 and the privacy of residents must be promoted at all times. Medication records were found to be accurately maintained. EVIDENCE: Two sample care plans were examined and seen to be of the required standard, except that the ‘wills and funeral wishes’ sections were not completed. Case tracking was undertaken on the two examples, one of which was service users in the dementia unit. All service users are registered with the Harefield Health Centre. The ‘company car’ is used to take residents to medical appointments, but GPs do visit the home as necessary. One was observed doing so and a chiropodist was undertaking her quarterly visit on the day of the inspection. A sample of medication records were examined and approved. One service user receives a controlled drug: temazepam. At lunchtime on the ground floor, once service users are seated in the dining room, their walking frames are stored in a nearby service user’s bedroom. The service user had not formally given her permission for this to happen. It is therefore an invasion of her privacy and a more suitable storage space must be located or built for all items of mobility assisting equipment wherever Coppermill Care Complex Version 1.10 Page 10 appropriate throughout the building. It is understood that the kitchen and dining area are due to be extended out into the garden and so perhaps additional storage for equipment can be created at the same time. One service user’s bedroom had the lock removed. Coppermill Care Complex Version 1.10 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Specialist activities in the dementia unit need to be developed for the benefit of service users there. Service users’ religious needs are met and visitors and community activities are encouraged. Service users are consulted about activities and food choices and encouraged to control their own finances. On the day of the inspection, lunch was served 45 minutes late at 1.30pm which is not in service user’s best interests. EVIDENCE: Care plans examined demonstrated that service user’s interests, likes and dislikes were recorded. The activity co-ordinator for the downstairs floor was met and a programme of activities and outings seen and discussed. Unfortunately the activity coordinator for the dementia unit had resigned, and her replacement had not yet started so a programme of specialist activities was in abeyance. The company car is used to take service users to a church of their choice. A catholic priest visits two service users, and a further two have visits from Jehovah Witnesses. An average of 15 visitors per day sign the visitors’ book. School children visit to sing carols at Christmas. Coppermill Care Complex Version 1.10 Page 12 Service user meetings are held quarterly and records demonstrate that consultation takes place. Service user meetings are held annually. Three service users control their own finances. Lunch is always served in the dementia unit after the ground floor. There was a delay in serving lunch on the ground floor that was varyingly put down to staff talking to the inspector, the need to make sure the meat was fully cooked, and waiting for the chiropodist to finish her work so that all service users could eat together. Certainly one service user declined to eat her meat, claiming it was too tough. Attention needs to be paid to cooking time and the quality of meat served, if this is an issue. 45 minute delays are not acceptable whatever the cause. The routine must also be flexible enough so that if a delay on the ground floor is unavoidable, consideration may be given to serving the service users on the other floors first. Coppermill Care Complex Version 1.10 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Service users benefit in so far as the NMS concerning complaints is fully met. However the home’s adult protection policy needs to be rewritten in order to achieve the same outcome. EVIDENCE: Three complaints were recorded since the last inspection, two of which were from the same complainant. Records demonstrated appropriate investigations had taken place and responses given. A copy of the complaints procedure, together with the last inspection report, and outcome of the last customer survey are all displayed in the foyer of the home. The home has obtained a copy of Hillingdon and Ealing Council’s Adult Protection Procedures. However the home’s own protection policy indicates that instances of abuse should only be reported to the local Council’s Adult Protection Team with the permission of the service user. All instances of suspected abuse must be reported. The Registered Manager needs therefore to rewrite this aspect of the home’s procedure accordingly, and to train the home’s staff in the revised policy. Coppermill Care Complex Version 1.10 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected 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 environment for service users is not totally safe or secure and urgent action must be taken on the Health and Safety aspects identified below. Bathing facilities on the top floor are not adequate to meet service user’s needs. Adequate storage space must be created for walking frames, wheelchairs and hoists in order to improve privacy for service users and to keep the home looking pleasant and homely. This will be aided if communal service user’s areas such as toilets and bathrooms are made more attractive and do not have instructions for staff stuck to the walls. The environment in the dementia unit (first floor) was not ideal for service users due to the smell of urine and low standard of carpet cleaning. Rather than replace more carpet which would be only a partial solution and make the home less homely, urgent consideration needs to be given to more regular deep cleaning of carpets, and additional continence promotion. Hot water for the benefit of service user’s use is not at the optimum temperature. EVIDENCE: Coppermill Care Complex Version 1.10 Page 15 The location of the home is not ideal due to its isolation from community facilities but the provision of a company care helps. The design of the home is not perfect but some improvements have been made and others are planned. A planned maintenance schedule has been introduced. Two outstanding maintenance items were observed and reported to the Registered Manager. These were a missing lock on a service user’s bedroom door, and the fire door to the kitchenette on the top floor which would not close properly. These items suggest that the reporting system for building faults, requires some refinement. The cleaning stores on ground and first floor were found to be unlocked and the domestic staff reported they did not have keys for the stores issued to them. This was addressed and put right at the time of the inspection. As the stores contain hazardous materials, they must be kept locked at all times (COSHH regulations). On the top floor, the stand-alone shower cannot be used by anyone unable to step into the raised shower tray. There is a conventional bath with shower attachment but no fixed hoist to aid entry. Service users of this floor who need such a facility have to go to the facility on the floor below. This must be avoided by improving the bathing facilities on the top floor. As reported above walking frames were temporarily stored in a bedroom during lunch. Two wheelchairs were seen to be stored in a bathroom. Bathrooms and toilets were not decorated beyond a coat of cream emulsion paint. Most had hand written signs blutacked to the walls reminding staff not to flush pads down the toilet etc. A storeroom has the COSHH regulations posted on the outside rather than the inside. Instructions for staff should not be visible to service users as it detracts from the homely environment that a care home should be. A strong smell of urine was noted at one end of the first floor dementia unit. The carpets in corridor and lounge of this unit are very soiled. These are due to be replaced by vinyl. However this should be seen as a last resort, as more regular complete cleaning of existing carpets is to be preferred in order to maintain the homely atmosphere and to avoid creating a hospital like or institutional facility. It is not known whether the homes’ washing machines are fitted with nonreturn valves to prevent dirty water from entering the home’s water supply. The laundry was not inspected but was said to be too small and due to be extended. The temperature of hot water was tested at three places and was warm rather than hot. It should be at close to 43 degrees Centigrade. Coppermill Care Complex Version 1.10 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 28, 29 NMS 28 may be met but although few care staff have NVQ care qualifications, several are qualified nurses from abroad. There was no evidence of this affecting outcomes for residents either way. NMS 29 indicates that new care staff should not commence work in the home until they have obtained a satisfactory CRB check. This is a major concern to be resolved that could affect service users adversely. EVIDENCE: Recruitment has taken place so that there are no vacant posts and no use of agency staff. The replacement activity co-ordinator has not started yet. Two new staff members, who are qualified nurses from Rumania, were commencing their induction on the day of the inspection. They had been recruited by Complete Care Solutions Ltd of Redbridge and would be housed in a company house in Harefield. They did not have CRB’s and hence they will not work unsupervised until Coppermill has obtained satisfactory disclosures. The NMS says new staff are confirmed in post only following completion of a satisfactory police and POVA check. Although it is nine months since the last inspection when it was made a requirement, two members of the existing staff still do not have CRB’s. Some staff have not yet provided photographs for their staff file. The staffing level is 10 at anyone time during the day, and records demonstrated this to be met. The Registered Manager will make enquiries from the successor organisation to TOPPS as to how nursing qualifications compare to NVQs so that a judgement can be made concerning NMS 28 and the requirement to achieve a minimum ratio of 50 trained care staff. Coppermill Care Complex Version 1.10 Page 17 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, 34, 35, 36, 37, and 38. All of the outcomes for service users are being met, despite some shortfalls such as designated budgets for the manager’s use, except NMS 38. This judgement is based on the Health and Safety issues identified elsewhere in the text. EVIDENCE: The Registered Manager has been registered as the manager of Coppermill Care Complex since the last inspection. His qualifications, skills and knowledge have been deemed to be appropriate. He has produced and implemented much of an action plan that has improved outcomes for service users. This includes operating the home in an open, positive and inclusive way, reorganising the management structure, aspects of the staffing structure, and introducing new policies and procedures A Quality Assurance plan has been created. The first audit using it is due in September this year. Coppermill Care Complex Version 1.10 Page 18 Records on how service users own personal allowances were being spent were examined and found to be in order with money being spent appropriately and not on items that the home should provide. Formal supervision of staff on a two monthly basis has recently commenced as per records seen. The manager does not have set budgets to work to, which he has requested, and which is recommended practice. Coppermill Care Complex Version 1.10 Page 19 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 2 2 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 1 3 2 2 3 2 2 1 STAFFING Standard No Score 27 x 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 2 3 3 3 1 Coppermill Care Complex Version 1.10 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 and 5 Requirement The Statement of Purpose and Service Users Guide must be updated, and make reference to respite care Service users who are funded by a Local Authority must have a statement of terms and conditions In order to maintain service users privacy and dignity, occupied bedrooms must not be used for storage. additional storage for mobility assisting equipment must be created or built where-ever needed throughout the building Specialist/relevant activities must be identified and provided in accordance with service users assessed/changing needs (in the dementia unit) This is partially restatedfrom the previous inspection report. Food must be properly prepared, and available at such times as may reasonably be required by service users. The homes adult protection must be re-written and staff trained in its use The procedure for reporting and Version 1.10 Timescale for action 30 June 2005 31 August 2005 30Novemb er 2005 2. 2 5 (1) (b) (c)(3) 12 (4) (a) and 23 (2) (l). 3. 10 and 22.7 4. 12 16 (2)(n) 30 June 2005 5. 15 16 (2) (i) 30 June 2005 31 July 2005 30 June Page 21 6. 7. 18 19 13 (6) 13 (4) (a Coppermill Care Complex 8. 9. 10. 19, 24 and 38 19 and 38 19 and 38 and c), and 23 (2) (b) 12 (4) (a) 23 (4) (a) 23 (2) (l) and 13 (4) correcting faults in the building must be improved 2005 11. 21 and 22 23 (2) (j and n) 13 (3) 12. 26 13. 26 23 (2) (d) 14. 15. 25 29 13 (4) 19 (1) (b) and Schedule 2 (7) (a) 19 (1) (b) and Schedule 2 (1) 16. 29 All service users bedrooms must 30 June be lockable. 2005 All fire doors must close correctly 30 June 2005 All cleaning chemicals must be 30 June 2005 kept under lock and key. Domestic staff must be trained in recognising and reporting COSHH hazards. The risk assessment of the building must cover the safe storage of cleaning materials. Bathing facilities on the top floor 31 August must be improved to meet the 2005 needs of physically disabled residents The manager must ascertain 31 July and confirm to the CSCI that the 2005 washing machines comply with the Water Supply (Water Fitting) Regulations. (non-return valves). Ways need to be found to 30 June prevent communal areas 2005 smelling of urine, and carpets must be kept clean Hot water used by service users 31 July must have a temperature close 2005 to 43 degrees Centigrade CRB (Criminal Record Bureau) 30 June checks must be carried out for 2005 all members of staff. This requirement is restated from the previous inspection and the one before that). A recent photogragh must be 30 June obtained of each staff member. 2005. This requirement is restated from the previous inspection. Coppermill Care Complex Version 1.10 Page 22 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. Refer to Standard 19 28 Good Practice Recommendations The home should be made as homely as possible by not having instructions for staff displayed where residents see them as well. At least 50 of the staff team should achieve an NVQ level 2 (or equivalent) by 2005. This recommendation is restated from the previous inspection. The Registered Manager should enquire from the successor organisation to TOPPS whether nursing qualifications from abroad count as equivalent qualifications. The manager should be delegated by the proprietor budgets to work to. 3. 34 Coppermill Care Complex Version 1.10 Page 23 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Coppermill Care Complex Version 1.10 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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