Inspection on 05/10/06 for Coppermill Care Centre

This inspection was carried out on 5th October 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Coppermill Care Centre 24/10/05

Coppermill Care Centre 23/05/05

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 6TG Lead Inspector Robert Bond Key Unannounced Inspection 5th October 2006 09:30 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.V310930.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. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coppermill Care Complex Address 10 Canal Way Off Summerhouse Lane Harefield Middlesex UB9 6TG 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.V310930.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 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. Referrals are taken from self-funding service users but many service users are funded by Local Authorities, in particular the London Borough of Hamersmith and Fulham, and the London Borough of Hillingdon. The fees range from £375 to £670 per week. Respite care is offered in some circumstances, for a minimum period of two weeks. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is a ‘key’ inspection that considers the home’s performance against the key National Minimum Standards (NMS) for Care Homes for Older People as published by the Department of Health. The Inspector spent 5 and a half hours at the care home. As the Registered Manager was on leave, the Inspector interviewed the Administrator, one of the Floor Managers and one of the Activity Co-ordinators, he met other staff, talked to service users, toured the premises, and examined a variety of records including ‘case-tracking’ four care files. The Administrator reported that the home was fully staffed with no agency staff being used, and that there were six vacancies for service users, one in the dementia care unit, and five on the ground floor that is registered for older people without dementia. The Inspector assessed the outcomes of 22 of the NMS, and found that 2 were exceeded, 15 were fully met, whilst 5 were only partly met. This led to the Inspector making 6 requirements and 2 recommendations. What the service does well: What has improved since the last inspection? A substantial amount of redecoration and reflooring has taken place. New chairs have been purchased for use on the second floor. A hoist has been installed in a second floor bathroom. Bathrooms have been better decorated and now contain cabinets. A additional refrigerator has been purchased for the use of staff members. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 6 Improved storage arrangements are in place for wheelchairs and vacuum cleaners. Better records are now kept of service users’ religions, and a monthly religious service is led by a Church of England vicar to which people of all faiths are welcomed. The Registered Manager has a detailed budget plan to work to. The home has a Business Plan in place. Further staff have received NVQ training and other relevant training. The Registered Manager has undertaken the Registered Manager Award training. A new menu has been agreed and special monthly meals with wine are now served. What they could do better: When an assessment of a prospective service user has been undertaken by the care home, the service user and/or their representatives must be notified in writing of the outcome of the assessment in terms of whether or not the care home is able to meet the needs of the prospective service user. When a new or revised individual care plan has been drawn up by the care home, the service user or their representative must in all cases be encouraged to sign it. This will provide evidence that the service user or their representative has been consulted about and has agreed to the contents of the care plan. The current hairdressing arrangements must be improved so that the smell of hair dressing chemicals does not pervade the foyer, and so that service users do not have to sit in the foyer whilst their hair is being dried, as their privacy and dignity is not being maintained by this practice. The Staff Room is currently kept unlocked with the door wedged open. In its current position off the Foyer, this creates a potential hazard for service users who may wander in, and is not a secure place for staff members to keep their personal possessions. The door should be kept closed, and the door locked when the room is unoccupied. Additional staff lockers must be provided. The smell of incontinence in parts of the first floor dementia care unit must be eradicated. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 7 It is recommended that the use of personal symbols such as a cat or a dog on the bedroom doors within the dementia care unit is extended if it is shown that additional service users will benefit from being able to more easily recognise their own bedroom door as a result of a symbol that has deep personal meaning to the service user. It is recommended that toilet doors throughout the home are marked with a suitable symbol to help service users (and visitors) identify what is behind the door as not everyone can read and understand the word ‘toilet’. 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.V310930.R01.S.doc Version 5.2 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.V310930.R01.S.doc Version 5.2 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): 3, 4 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. No service user moves into the home without their needs being assessed. This is done appropriately but the service users and their relatives are not being assured in writing that those needs will be met. The home does not provide intermediate care. EVIDENCE: The Inspector examined in detail (case-tracked) four care files, two from the dementia care unit, and two from the non-dementia ground floor. Two files were for new service users, two files were for service users who had been resident for over a year. One service user was self-funding, one was financially supported by the London Borough of Hammersmith and Fulham, and two were financially supported by the London Borough of Hillingdon. The latter two had both been in other care homes initially, that could now no longer meet their care needs. In all the above instances, a member of staff from the care home had undertaken a full and appropriate assessment of needs. The Care Regulations Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 10 state that where a referral has been made by Local Authority following care management procedures, a community care assessment should be supplied to the care home. On the files examined by the Inspector, the London Borough of Hammersmith and Fulham had supplied this document, but the London Borough of Hillingdon had not done so, but perhaps the form had been sent to the care homes who initially provided the care, and those care home had not forwarded the documents to Coppermill. The Care Regulations also require that once an assessment done by the care home indicates that the care needs of a prospective service user can be met by the care home, the Registered Manager must confirm this in writing. There were no letters on file to this effect. The Administrator said she thought the Registered Manager did this verbally at present. See Requirement 1. The mental health section of one of the internal assessments was not fully complete. Two of the handling assessments were not signed and dated in the correct place. However in general the quality of the assessments was good, and the information had been appropriately transferred onto individual service user care plans. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The services users’ health, personal and social care needs are set out in excellent individual plans of care, but the service user or their representative should be signing their agreement to the plan more often than at present. Service users are sufficiently enabled to make decisions about their lives, with assistance as needed. Service users are well protected by the home’s policies and procedures for dealing with medicines. Service users are treated with sufficient respect and dignity except in relation to the current hairdressing arrangements. EVIDENCE: The Inspector examined the individual service user care plans in each of the four files he case-tracked. The Inspector found that all the care plans seen followed the same format that was clear, detailed, and which identified needs, goals, and necessary actions. The format is commended. The care plans were all evaluated, reviewed and updated as necessary, on a monthly basis. One file Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 12 seen contained a formal review by the Local Authority care manager in March 2005. There was no evidence of a subsequent formal review in March 2006. Although the care plan format used has a space for the service user to sign their agreement to the care, none of the four had done so. It is the Inspector’s view that two of the service users would have been able to sign in order to demonstrate their involvement in drawing up and agreeing to the care plan. In other instances, perhaps a relative or representative would be willing to sign their agreement, on behalf of the service user. See Requirement 2. Care plans and other records on the care files were seen by the Inspector to contain relevant health information. Evidence was seen of regular weight checks for service users, and appointments for appropriate health care including skin care, and eye-sight care. Chiropody, dentistry and nursing input were also identified. The Administrator reported that nutritional and dietary needs are assessed and recorded on ‘the menu list’ for action by the catering staff. One GP’s practice covers the whole care home. The Inspector checked the medication storage and medication records for the downstairs unit. The Inspector checked the controlled medication records for the home, and the returned to pharmacy medication records. All were in order. The Inspector noted that service user’s bedroom doors were closed, and that staff members knocked on doors before entering. The Inspector observed staff providing care in a way that enhanced service users privacy and dignity. The only exception concerns the provision of hairdressing but this is not a criticism of the hairdressing staff at all, but a criticism of the facilities available to them. On the day of this inspection, hairdressing was taking place. The hairdressing room is situated directly off the entrance foyer. It is a small room with no natural light or natural ventilation. It has an electrical extractor fan but this is probably insufficient. The Inspector was aware of the smell of chemicals used in hair-dressing when he arrived in the foyer as the door to the hairdressing room was open. Subsequently he found that in addition to two service users having their hair done within the room, a further two service users were sitting in their hair curlers having their hair dried in the foyer. This situation is not conducive to respecting the privacy and dignity of service users at all times, as required by the Regulations. The size and location of the hairdressing room in current use are inappropriate bearing in mind the size of the home and the demand for service. This is not however a request by the Inspector to cease or cut back the hairdressing service overall, as good hair care has substantial benefits in promoting mental and emotional well-being. See Requirement 3. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users social, cultural, religious and recreational needs are very well assessed and met. Service users maintain contact with family, friends and community to a good extent. Service users are helped to exercise choice and control over their lives to a satisfactory extent. Service users receive a good wholesome appealing balanced diet, with choices available, in pleasing surroundings and at appropriate times. EVIDENCE: The Inspector observed activities underway, examined individual the recording of individual social needs and interests, noted the programme of weekly activities, and one-off activities, and interviewed one of the activity coordinators. He noted that she has training in the provision of activities for service users with dementia. The activity co-ordinator reported that she is preparing with individual service users life histories and scrapbooks. This, and the programme of activities which is geared towards the needs of all the service users, are commended by the Inspector. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 14 Recent outings have included Windsor castle, a canal-boat trip, a Thames river-boat trip, and the theatre. The Inspector was able to verify this when he checked the expenditure records of service users. A Church of England vicar attends monthly to lead a religious service. The service is open to people of all faiths. The Administrator confirmed that at weekends a substantial number of service users are visited by and/or taken out by relatives. The Inspector confirmed this by examining the visitors’ book. The Inspector observed a mid-day meal being eaten in a relaxed manner, on time and in pleasant surroundings. The main meal choice was between chicken casserole and steak and kidney pie. Some service users told the Inspector they did not like their meal whereas others said ‘it was lovely’. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Complaints from service users and their relatives are properly investigated and documented. Service users are adequately protected from abuse. EVIDENCE: The Inspector noted the home has an up to date complaints procedure and policy. The Inspector examined the home’s complaints file. It contained one complaint from a Local Authority care manager concerning the care of two service users. The complaint had been thoroughly investigated by the Registered Manager and appropriate action had been taken. The Inspector is aware of another complaint concerning charges. The Administrator reported that the papers on this complaint were held by the Proprietor. The Inspector subsequently spoke to the Proprietor and was assured that the complaint was being dealt with. The Inspector requested that he be sent a copy of the response letter that would be sent to the complainant by the Proprietor. The home has a file containing 25 letters of compliment. The Inspector noted that the home has a revised Adult Protection policy in place, follows the London Borough of Hillingdon POVA procedure, and the majority of staff have received the appropriate training. Those staff members Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 16 who have not yet been trained in POVA (now called Safeguarding Adults) have training dates arranged during November and December 2006. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users live in a reasonably safe and well-maintained environment. The home is satisfactorily clean, pleasant and hygienic except for the unpleasant smells in parts of the dementia care unit. EVIDENCE: The Inspector toured the premises in the company of the Ground Floor Manager. Issues about the Hairdressing Room are contained in the ‘health and personal care’ section of this inspection report. The Inspector noted that a Staff Room also opens off the main foyer of the home. This in itself is not a problem, but the fact that the door to the Staff Room is left open could be a problem in that personal possessions, money, and Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 18 medication were all found in unlocked cupboards within the room, and documents that could be confidential. Thus to protect service users from potential hazards within the Staff Room, to protect the property of staff from interference and theft, and to maintain confidentiality, the Staff Room door should be kept closed, and when not in use, kept locked. Requirement 4. Within the refrigerator in the Staff Room, the Inspector found a phial of insulin that had been put in there by a visiting nurse. This fridge is for food only, and is not a secure place to store medication, in any case. The Inspector asked to see the provision of staff lockers in the care home and was shown a stack of 16 lockers on the second floor back landing. Two lockers had broken locks. Given this fact and that several handbags were seen to be stored in a cupboard in the Staff Room, it is reasonable to surmise that the number of working lockers are insufficient for the number of staff employed and hence the provision of additional lockers is required. Requirement 5. The Inspector noted the improved storage arrangements for wheelchairs and vacuum cleaners, and noted that many areas had been redecorated, and some carpets had been replaced by wooden flooring. Some bathrooms had been decorated with pictures and stencil painting, some baths had been replaced by showers and a hoist had been installed in a second floor bathroom. The home was found to be generally clean and hygienic throughout, except that there was an unpleasant aroma of incontinence in the lounge and in the communal area of the dementia unit on the first floor. Every effort must be made to eradicate the smell. Requirement 6. The Inspector noted that within the dementia care unit, two bedroom doors have pictures of animals upon them. This is a useful device for some service users to assist them to find their own bedroom. It is recommended that the system of using an easily recognisable symbol that has personal significance on bedroom doors is extended where there is an identified benefit for individual service users for doing so. Recommendation 1. All the toilet doors throughout the care home are labelled ‘toilet’ but the Inspector noticed in the dementia care unit how similar all the doors within the unit look at first glance. For someone with failing eye-sight or failing ability to read, this could be a problem. A care worker the Inspector spoke to about this said any service user who needed assistance to find a toilet would be taken to one. However part of the ethos of a care home should be to promote independence also. Hence the clear labelling of toilets is part of the process of promoting independence and of promoting continence. Therefore it is recommended that an easily recognisable symbol for a toilet is placed on all communal toilet doors throughout the home. Recommendation 2. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users needs are well met by the numbers and skill mix of staff. Service users are in satisfactorily safe hands at all times. Service users are well supported and protected by the home’s recruitment policy and procedures. Staff members are well trained and well competent to do their jobs. EVIDENCE: The Inspector examined a variety of staff rotas. The home is fully staffed and no use is being made of agency staff at the present time. The Administrator reported that when agency staff are used, they are fully vetted. The Administrator reported that when the present staff members who are undertaking NVQ’s complete their courses, the home will meet the target of having over 50 qualified staff in post. The Inspector examined a sample of training needs analyses for staff members, and saw the home’s annual training plan. He noted in particular that several ‘Understanding Dementia’ courses had been and were being arranged, and that by January 2007, all care staff should have received this training. The Inspector examined a staff recruitment file and found that all appropriate checks had been undertaken. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 20 Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users live in a home that is very well run and managed by a manager who has been registered by CSCI. The home is run sufficiently in the interests of service users. Service user’s financial interests are sufficiently safeguarded. The health, safety and welfare of service users and staff are well promoted and protected. EVIDENCE: The Administrator reported that the Registered Manager has completed his Registered Manager Award. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 22 In terms of quality assurance, annual surveys of service users are undertaken. The Inspector saw a summary of the responses received. An audit of the home is undertaken annually by a consultant. The Administrator reported that the home is soon to seek Investors in People accreditation. The home has a business plan for the next year, and beyond. All the above is commended, as the NMS is exceeded. The Inspector checked the Regulation 26 Reports that the CSCI had received from the Proprietor and found that the last one on file was dated February 2006. As these are required to be submitted monthly, the Administrator agreed to investigate whether they had been faxed to the CSCI correctly. The Administrator reported that three service users manage their own finances, with the care home dealing with most of the rest. The Inspector checked a random sample of the records kept, and found them to be in good order, with the expenditure of service users’ money being on appropriate extras such as hairdressing and outings. The Inspector checked a variety of health and safety records such as fridge and freezer temperatures, first aid box contents, risk assessment of the property, lift safety certificate and water safety certificate. All were in order. Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 15 2 x x x 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 4 x 3 x x 3 Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation 14(1)(d) Requirement The registered person shall confirm in writing to the service user that having regard to the assessment, the care home is suitable for the purpose of meeting the service user’s needs in respect of health and welfare. The registered person must consult with the service user and/or their representative where possible in drawing up the service user plan. A signature is the best way of evidencing the consultation and agreement of a service user or their representative. The registered person must ensure the care home is conducted in a manner which respects the privacy and dignity of service users, hence the current hairdressing arrangements must be improved. The contents of the Staff Room must be kept secure in order to protect service users from potential harm. The registered person shall DS0000038202.V310930.R01.S.doc Timescale for action 01/11/06 2 OP7 15 01/11/06 3 OP10 12(4) 01/12/06 4 OP19 13(4)© 01/11/06 5 OP19 23(3)(aii) 01/12/06 Page 25 Coppermill Care Complex Version 5.2 6 OP26 16(2)(k) provide for staff adequate storage facilities. The registered person must keep the care home free from offensive odours. 01/11/06 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 Refer to Standard OP19 Good Practice Recommendations The practice of putting personalised symbols on bedroom doors in the dementia care unit should be extended if individual service user assessments indicate it is worthwhile. The toilet doors in the dementia care unit, and perhaps throughout the home, should be marked by a symbol as the word ‘toilet’ cannot be read and understood by everyone. 2 OP19 Coppermill Care Complex DS0000038202.V310930.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 DS0000038202.V310930.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!