CARE HOMES FOR OLDER PEOPLE
Coppermill Care Complex 10 Canal Way Off Summerhouse Lane Harefield Middlesex UB9 6HS Lead Inspector
Robert Bond Unannounced Inspection 24th October 2005 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 Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 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. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Coppermill Care Complex Address 10 Canal Way Off Summerhouse Lane Harefield Middlesex UB9 6HS 01895 820130 01895 820149 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) 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 DS0000038202.V254902.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd May 2005 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 DS0000038202.V254902.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a four hour period and included meeting with the manager to check compliance with the requirements of the last inspection, undertaking a tour of the home, speaking to staff and service users, observing the care provided, and examining records. In particular the Inspector ‘casetracked’ three service users’ care files, and three staff members’ recruitment and training files. On the day of the inspection, the Registered Manager reported that there were 3 service user vacancies, all on the Elderly Mentally Ill (EMI) unit, and staff vacancies comprised only one night care assistant and one domestic assistant. The Inspector assessed the home against the 21 key standards identified in the National Minimum Standards (NMS), and 3 extra standards. The Inspector made judgements concerning to what extent outcomes for each standard had been met, and concluded that 16 outcomes had been fully met, 8 had been almost met, and 0 had not been met at all. The Inspector made 8 requirements, of which 1 is carried over from the last inspection having not been achieved within the timescale set. The Inspector also made 4 recommendations. What the service does well:
The present Registered Manager has been in post for approximately one and a half years and during that time has re-organised the management structure of the home, created the activity co-ordinator posts and made many improvements. The level of care was observed to be of a good standard, and the design, decoration and furnishing of the premises are generally of a high standard also. There have been a number of improvements since the last inspection that will further improve outcomes for service users. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
The Registered Manager reported that he wished to undertake a public relations exercise to advertise the home better. The existence of three service user vacancies suggested to him that the existence of the home was not sufficiently well known. In terms of assessments of potential new service users, in order to make sure their needs can be fully met, the pre-admission assessment process needs to be amended slightly so that the person’s religion (if any) is always recorded and hence taken into account when providing service and meeting needs. The Registered Manager is keen to continue with his programme of refurbishment of areas of the home. However the Inspector found areas where redecoration, re-flooring and re-furnishing were all still required. Examples are, replacement of some lounge chairs, replacement of a carpet by a wooden floor in the upstairs lounge, and a hoist awaiting installation in a top floor bathroom. A lack of appropriate storage continues to be a problem and the Inspector found in one bathroom a hoist, a chair without a seat, a vacuum cleaner, and a variety of cosmetics. All of these should be stored elsewhere if possible so that all areas used by service users can be made more attractive for their benefit. Infection control was an issue that needs to be addressed and expert opinion obtained for the potential benefit of service users concerning the correct operating temperatures of certain refrigerators in the kitchen. Amongst the Inspector’s recommendations are two that if implemented the ambiance of the home would be improved still further for the benefit of service users and visitors to the home.
Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 7 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. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 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 the following standard(s): Standard 3. Standard 6 does not apply as intermediate care is not available. The outcome for Standard Three is not fully met for the reasons stated below. EVIDENCE: NMS3: The Inspector examined and ‘case-tracked’ the care files of the last three service users to move into the home. He found that all three service users had been assessed but a variety of assessment practices and quality of recording was evident. In particular it was noted, and agreed with Registered Manager, that the format of the home’s own assessment document should be altered slightly. Firstly, so that the design of the form encouraged the person completing it to record the service user’s religion in all cases, not just when the service user expressed a wish to attend religious services. Secondly, so that the date of the form’s completion and the name and role of the person completing it are clearly recorded. See Requirement 1. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. The outcomes for all these Standards are fully met for the reasons detailed below. EVIDENCE: NMS7: The Inspector examined three service user files and each contained a detailed care plan. Social needs, including interests, were recorded. Each file also contained a record of activities that each service user engaged in. NMS8: The care plans also detailed the physical and mental health of service users, with additional medical or nursing assessments where appropriate. The files also contained a record of each medical, nursing or paramedical input that the service user received since becoming a resident of the home. NMS9: The Inspector examined the home’s storage arrangements for medication, which were in order. He also examined a sample of the medication administration records, which also were in order. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 11 NMS10: Service users are able to lock their bedrooms, and have a lockable space within their room. The Inspector observed that service users were being treated with respect by the staff. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 12 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 The outcome for Standard 12 is not completely met for the reason stated below. The outcomes for Standards 13, 14 and 15 are fully met. EVIDENCE: NMS12: A service user who the Inspector spoke to confirmed that she went on outings organised by the home. As the Inspector has reported above, the religion (if any) of service users is not always being recorded during the home’s assessment of potential service users’ needs. As a result this important information is not always appearing in the Care Plan, and hence religious needs of individual service users may be inadvertently missed and not provided for by the home. See Requirement 2. NMS13: The Inspector examined the home’s visitors’ book that demonstrated the extent of visiting by relatives and friends. A service user the Inspector spoke to confirmed that her relatives visited and took her out. The Inspector also examined the minutes of a relatives and service users’ meeting with management, held on 18th October 2005.
Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 13 NMS14: The above meeting discussed the choice of meals, activities and outings. The Inspector also saw records of personal possessions new service users had brought with them when they moved into Coppermill Care Complex. NMS15: The Inspector examined the current menu, changed six monthly, which offers sufficient choice. The dining rooms are attractively furnished. A service user confirmed to the Inspector that she enjoyed the meals. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 14 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 and 18 The outcome for Standard 16 is not fully met for the reason stated below. The outcome for Standard 18 is fully met. EVIDENCE: NMS16: The Registered Manager reported that he had not received any complaints since the last inspection. The Inspector however had received one complaint that he had forwarded to the Responsible Individual (owner) of the home for investigation. The Registered Manager reported that he had never received a copy from the Responsible Individual hence he had no knowledge of it. The Inspector agreed to write to the Responsible Individual again, and send a copy of the complaint directly to the Registered Manager. It should be noted that this complaint does not concern the standard of care provided in the home. See Requirement 3. NMS18: Following comments made by the Inspector at the last inspection, the home’s adult protection policy has been revised. Staff members have been trained in its application. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 15 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, 21, 22 and 26. The outcomes for Standards 19, 21, 22 and 26 are not fully met for the reasons stated below. EVIDENCE: NMS19: The Inspector only found one instance where potentially service users were being put at risk. This was in the kitchen where three refrigerators are set to operate between 12 and 14 degrees Centigrade, as opposed to the usual 0 to 5 degrees. The Registered Manager said this was because the refrigerators stored cool drinks for service users. In practice these refrigerators were storing not only fruit drinks, but also milk, vegetables and cheese. The Registered Manager must seek expert advice from Hillingdon Council’s Environmental Health Team concerning the issues raised here. See Requirement 4. Elsewhere in the building, a refrigerator that had been installed in the EMI dining room for the specific purpose of storing cool drinks for service users, was found to contain only food that belonged to staff members. Staff should be provided with, and use, their own refrigerator. The temperatures of the
Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 16 refrigerator in the dining room were being recorded as per regulations, but the recording was in degrees Fahrenheit as opposed to Centigrade, which is the scale used elsewhere in the home. See Recommendation 1 and Requirement 6. In terms of maintenance, furnishings and decoration, the home is kept to a reasonable standard. The Inspector spoke to several members of staff who all confirmed that they had the equipment and training to do their jobs in a satisfactory manner. Many improvements have been made to the property since the last inspection, but further improvements are still required. The Inspector noted water damaged ceiling tiles in the downstairs corridor, a damaged kitchen unit in the EMI dining room, a broken clock face, some lounge chairs in need of replacement in the top floor lounge, and this lounge and nearby toilets in need of redecoration. The Registered Manager also reported that he is planning to replace a soiled lounge carpet with a wooden floor. See Requirement 5. NMS21 and 22: These two non-key standards were assessed because the last inspection report had identified a lack of suitable bathing facilities and equipment for physically disabled service users on the top floor of the home. As a result the Registered Manager has purchased a hoist for installation in the appropriate bathroom. The hoist however has not yet been installed. See Requirement 7. One bathroom visited contained a hoist, a chair with no seat, and a vacuum cleaner. This highlights the continued lack of appropriate storage areas in some parts of the home. Bathing should be as pleasant an experience as possible for service users, and the bathroom environment should be made sufficiently attractive. Requirement 8. NMS 26: The home was found to be generally clean, pleasant and hygienic. However the following issues were noted by the Inspector. A washing machine in the laundry has been broken down since 26/04/05. It should be removed if it cannot be repaired. The floor in the laundry is also damaged and must be made good. See Requirement 5. In a bathroom, it was noted that creams and talcum powder etc. were being kept behind the wash-hand basin. If it is necessary to store such items in bathrooms, those environments could be improved by the installation of bathroom cabinets. See Recommendation 2. A sign outside of the kitchen tells staff to wash their hands and don aprons and gloves before entering the kitchen. The plastic aprons and gloves are kept on a handrail which being in the main concourse of the building is a detracting feature to the otherwise pleasant ambiance. See Recommendation 3. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 17 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 to 30 The outcomes for Standards 27 to 30 are all met. EVIDENCE: NMS27: The Registered Manager reported that the only staff vacancies are a night care assistant and a domestic assistant. He has increased the number of domestic staff and as a result bedrooms in the EMI unit are now deep cleaned more regularly. Many of the care staff are from Eastern Europe, and have nursing qualifications. The Inspector examined the staff rota for the previous week and did not note any omissions. NMS28: The Registered Manager is seeking advice to determine whether nursing qualifications obtained in countries such as Romania equal or possibly exceed the standard of British NVQ’s level 2 and 3 in care. NMS29: The Inspector examined three recruitment files of new staff members and found that all appropriate checks including CRB’s had been undertaken. NMS30: The Inspector examined staff induction a nd training records and did not note any omissions. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 18 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): 31, 33, 34, 35 and 38. The outcomes for the Standards 31, 33, 34 and 35 are all met. The outcome for Standard 38 is not fully met for the reasons stated below. EVIDENCE: NMS31: The Registered Manager, who has professional qualifications obtained in Holland, is undertaking the Registered Manager’s award which he hopes to complete in June 2006. NMS33: The management hold regular consultation meetings with service users and their relatives. Minutes of a recent meeting were seen by the Inspector. Improvements have been made to the premises, its cleaning schedule, and activity programme, all of which are of direct benefit to service users. Questionnaires to ascertain the views of service users and their relatives
Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 19 have recently been completed. The Registered Manager said that a summarised outcome sheet will be forwarded to the CSCI when available. NMS34: A recommendation made in the last inspection report was that the Proprietor should provide the Registered Manager with designated and delegated financial budgets to work to. This process has only been partially completed. See Recommendation 4. NMS35: The Inspector examined the financial records of money held in the home on behalf of service users and found no errors, and that the money had been spent appropriately on items such as hairdressing and a trip to the Beck Theatre in Hayes. The Registered Manager reported that he wishes to dispense with the current system of holding cash that has been provided by relatives and replace it with an invoicing system. The only cash then held would be for service users without relatives. NMS38: The Inspector examined the record of hot water temperatures, and undertook his own check, he noted that the building’s passenger lift had been recently serviced, and that the building is being regularly risk assessed. The only outstanding concern is that of certain refrigerator temperatures as reported above. The Inspector would like the Registered Manager to obtain a written report from an Environmental Health inspector on this aspect. See Requirement 4. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 20 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 2 X X X 2 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 3 X 3 3 3 X X 2 Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) Requirement The needs of the service user must have been assessed by a suitably qualified and trained person. The registered person shall make suitable arrangements to ensure the care home is conducted with due regard to religious persuasion of service users. The registered person shall ensure that any complaint is fully investigated. The registered person must make suitable arrangements to prevent infection and toxic conditions arising in the home (by operating refrigerators at the temperature that is required to keep their contents fresh) The registered person must ensure that the home is kept in a good state of repair, that equipment is maintained in good working order, and all parts of the home are reasonably decorated. The registered person shall provide storage facilities for the use of staff.
DS0000038202.V254902.R01.S.doc Timescale for action 01/12/05 2 OP12 12 (4) (b) 01/12/05 3 4 OP16 OP19 22 (3) 13 (3) 01/12/05 01/11/05 5 OP19 23 (2) 01/01/06 6 OP19 23 (30) (a) (ii) 01/12/05 Coppermill Care Complex Version 5.0 Page 22 7 OP21OP22 23 (2) (j & n) 8 OP21OP22 23 (2) (l) Bathing facilities on the top floor must be improved to meet the needs of physically disabled service users. THIS IS RESTATED FROM THE LAST INSPECTION REPORT AS IT HAS NOT BEEN ACHIEVED WITHIN THE TIMESCALE SET. The registered person must ensure that suitable provision is made for the storage for the purposes of the care home. 01/01/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP19 OP26 OP26 OP34 Good Practice Recommendations The operating temperatures of refrigerators should be measured in degrees Centigrade which is the scale referred to in the appropriate Regulations. Bathroom cabinets could be installed in order to store toiletries. Plastic aprons and gloves for staff entering the kitchen should be stored in some other way or some other place than where they are currently stored. The process of the proprietor providing the registered managers with designated and delegated budgets to work to should be continued. Coppermill Care Complex DS0000038202.V254902.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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