Inspection on 28/09/04 for Coppice and Oakside

Care Homes For Adults (18 ­ 65)Coppice and OaksideShipley Common Lane Off Heanor Road Ilkeston Derbyshire DE7 8TSUnannounced Inspection28th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Coppice and Oakside Address Shipley Common Lane, Off Heanor Road, Ilkeston, Derbyshire, DE7 8TS Email address Tel No: 0115 9443690 Fax No: 0115 9443690Name of registered company United Health Name of registered manager Ms Marion Rosalind Atherton Type of registration Care Home No. of places registered 10Category of registration, (with number of places) Learning disability (10) Registration number C020000105 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 21st April 2004 If Yes refer to Part CCoppice and OaksidePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 328th September 2004 1.30 pm Brian MarksID Code071398Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionCoppice and OaksidePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementCoppice and OaksidePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Coppice and Oakside. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Coppice and OaksidePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Coppice and Oakside is a purpose built home offering 10 places for adults with a severe learning disability, set in 2 bungalows linked at the rear through the enclosed garden areas. The physical environment of the home was designed to a high standard, and is spacious and comfortable. The majority of the current resident group were admitted as part of the retraction programme of Aston Hall Hospital, near Derby, and all had spent long periods living in an institutional environment. The range of abilities demonstrated by the 2 groups of service users is quite different, with the 4 women in Oakside being more independent and having higher communication and self-help skills. Because of the levels of disability in the resident group, the home offers an intensive package of support on a 24 hour basis, and staffing levels are accordingly very high.Coppice and OaksidePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection focuses on the areas that are most significant for service users lives and the areas that were identified for action and development at the last inspection of this service, which took place on 21 April 2004. For a full overview of performance against standards this report should be read in conjunction with the report of the first full audit of this service, which took place on 13 November 2002. The inspector used case tracking methodology which involves the examination of records/documents discussion with the individual service users, staff (and where appropriate relatives) and evidence in relation to individual service users to determine how the National Minimum Standards work for them in practice. Two service users were case tracked during this inspection visit. Choice of Home (Standards 1 - 5) 2 out of 5 standards assessed.2 out of 2 assessed standards have been met. Planned admissions have been made at the home since it was opened, although the majority of service users were part of a hospital closure plan. There was a detailed admission procedure and this included extensive multi-disciplinary work. All service users had individual contracts of residence and strategic purchasing contracts in place. Individual Needs and Choices (Standards 6 - 10) 2 out of 5 standards assessed. 2 out of 2 assessed standards have been met. All service users had extensive individual care plans and these were evaluated on a monthly basis. The assessment of risk was central to the care planning process and detailed documentation was in place for all service user files examined. Lifestyle (Standards 11 - 17) 2 out of 7 standards assessed. 2 out of 2 assessed standards have been met. The majority of service users continued to receive visitors and access to local specialist social clubs was encouraged. A parent spoken to during the visit was very positive about care at the home. Standards of catering were good and arranged in a domestic style. Personal and Healthcare Support (Standards 18 - 21) 2 out of 4 standards assessed. 2 out of 2 assessed standards have been met. General health care was well managed at the home as was the management of medicines on behalf of the service users. Concerns, Complaints and Protection (Standards 22 - 23) 2 out of 2 standards assessed. 1 out of 2 assessed standards have been met. A satisfactory complaints procedure had been introduced at the home and a copy was on display. Records indicated that no formal complaints had been received at the home since the last inspection. Not all staff had received training in issues around the protection of Coppice and Oakside Page 6 vulnerable adults and the reporting of abuse. Environment (Standards 24 - 30) 3 out of 7 standards assessed. 3 out of 3 assessed standards have been met. The home had been developed as a high quality physical environment and standards of provision and maintenance had continued this. All bedrooms and communal spaces are well above the minimum standard and the redecoration programme of bedrooms in both bungalows had been completed. Staffing (Standards 31 - 36) 5 out of 6 standards assessed. 4 out of 5 assessed standards have been met. The homes operates good staffing arrangements developed centrally by the company and staffing levels were set high to meet the specialised needs of the service user group. The use of agency staffing to fill gaps in the rota had remained due to continuing vacancies but this was not excessive. All staff were subject to a check by the Criminal Records Bureau (CRB) before commencing employment. Staff reported that levels of training activity had continued; new staff were subject to a formal induction programme. A system of formal supervision/consultation with staff had not been developed. Conduct and Management (Standards 37 - 43) 1 out of 7 standards assessed. 0 out of 1 assessed standard have been met. General administration and management of the home was carried out to a satisfactory standard and staff were positive about the support they receive. There were some shortfalls noted in health and safety issues but this also a well-managed aspect of the homes activities.Coppice and OaksidePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action The following requirements are outstanding from the previous inspection dated 13.11.02. 10 13(6) YA23 The registered person must provide all staff with training in the recognition and reporting responsibilities in relation to the abuse of vulnerable adults. The manager must develop a formal system of staff supervision for all staff. All staff must receive instruction in food hygiene and infection control. The following requirements are outstanding from the previous inspection dated 21.04.04. 1 13(4)(a-c), 23(4)(a)(c) YA42 The registered provider must provide a written submission to the CSCI regarding the need for regular servicing of electrical fire safety equipment. 30.06.04 now 30.11.04 Ongoing1818(2)YA3631.08.03 now 30.11.04 Ongoing2213(3), 18(1)(c)YA42Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Coppice and Oakside Page 8 Standard The following recommendations are outstanding from a previous inspection dated 13.11.02. 2 5 YA23 YA35 The manager should attend the Social Services briefing in relation to the abuse of vulnerable adults. Induction and foundation training should be provided to all newly appointed staff in line with Learning Disability Award Framework (LDAF) standards. A copy of the financial plan for the home should be available for inspection. There are no recommendations outstanding from the previous inspection dated 21.04.04.7YA43CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Coppice and OaksidePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 18(1)(c), 23(4)(d) YA42 All staff must receive training in relation to the fire safety of the home at least annually for day staff and twice a year for night staff. 31.12.04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The homes management should review the current care planning documentation and establish a system that is `service user led rather than care led.1YA6* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this reportCoppice and OaksidePage 10 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES NO NO YES YES YES YES NO YES NO NO YES YES NO NO NO NO YES NO YES 0 1 0 YES YES YES YES 19 0 28/09/04 1330 4.0The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded Coppice and Oakside (Commendable) Page 11 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Coppice and OaksidePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 769 925 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence Not specifically assessed at this visit. Hairdressing, chiropody, toiletries. Standard met?0Coppice and OaksidePage 13 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? As the majority of the current service users were admitted as part of the closure programme of a local hospital or as a planned activity from home, a wide range of professional assessments were available prior to admission. As part of the case tracking process examples of these were examined and found to be comprehensive. The admission procedures of the home indicated that careful selection and referral would apply for new referrals. The high level of impairment they demonstrate limited the involvement of the service users themselves in this process. An advocacy service was developed alongside the retraction of the hospital and the views of families were very much to the fore. The service user groups in each of the bungalows was very different, with the 4 in Oakside having higher verbal and physical skills and more involvement in self care and speaking out for themselves; the culture of this part of the home was there very different from that of the Coppice. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Coppice and OaksidePage 14 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? All service users had been supplied with a copy of the contract details between the company and the relevant sponsoring local authority and these were kept on file. The service user guide contained a sample of an individual contract between the home and individual service user and this had been completed on behalf of any of the service users and placed in their bedrooms.Coppice and OaksidePage 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? From the individual files examined as part of the case tracking process, it was demonstrated that a detailed care plan has been developed for each service user and this was set out within a goal orientated format; because of the levels of impairment, the service users did not meaningfully contribute to these. Internal evaluations had occurred on a monthly basis and these were signed by the keyworker, whilst more strategic reviews with family members and/or external agents, had occurred from 6 to 12 months depending on individual circumstances. Risk assessments that covered manual handling, activities and tissue viability (Waterlow) had been completed. All service users had been allocated and external care manager to oversee care. It had been previously stated by the homes manager that there were plans to review care planning documentation, and this had had occurred for 1 service user and the others were in the process of transferring to the new system. As had previously been stated the current arrangements were cumbersome to use effectively and were care led rather than `service user led. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Coppice and OaksidePage 16 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? The assessment of risk was central to the homes planning of care, and as noted above, the files examined contained details of those carried out for the individual service users. These included activities related relation to leisure and community access. The management of risk was also related to the provision of additional staffing and flexibility was demonstrated in this area on occasions when 1-to-1 support was used to allow for outings and outside activities. A policy in relation to missing persons was present and those service users identified as likely to abscond have a reference to this in their personal risk assessment. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Coppice and OaksidePage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Coppice and OaksidePage 18 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? Not specifically assessed at this visit.0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Although 1 resident was reported to receive no family visitors, staff reported that links had been maintained by all of the others, some enjoying very regular contacts, including overnight stays at the family home, and an open visiting policy was maintained by the home. One parent was present during the inspection visit and he commented favourably on the standards of care at the home and confirmed that he had an open visiting arrangement. He had also continued to involve himself with his daughters care and staff confirmed that this was the homes policy also.Coppice and OaksidePage 19 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The menu had been retained as 4-weekly within Coppice, and weekly within Oakside. Shopping was from local supermarkets and stores and service users help out with this activity on a routine basis; this activity had just been completed within Oakside during the visit. The style of the menus remained one of healthy eating, and a good variety of cosmopolitan and traditional items had been tried out with residents. Further variety and flexibility were demonstrated by the regular addition of meals from local takeaway restaurants and on picnics, and the staff spoken to felt that a good balance had been achieved by some trial and error. Staff confirmed that 3 residents in Coppice needed assistance at mealtimes and the diets of 2 others were regularly monitored and reported in care plans; this involved both build-up and reducing diets. The kitchen was of a good size, being domestic in style and equipment, and food storage was arranged satisfactorily.Coppice and OaksidePage 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 013 Key findings/Evidence Standard met? The service users are registered with 2 local GP practices and the level of support continued to be satisfactory. Records examined on case files indicated some annual health checks being carried out, such as dental, optical and reviews of medicines and of regular visits to outside clinics and outpatients; this usually required some advance planning and staff support. Staff reported that a number of the service users had received additional involvement from outside healthcare professional including dietician, district nurse, speech and language therapist and psychologist. The service users were described by staff as being in generally robust good health.Coppice and OaksidePage 21 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? There were no residents who managed their own medication. Staff had received appropriate training on an external course on the management of medicines. Examination of the medicines administration system indicated satisfactory arrangements being in place at the time of the inspection.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Coppice and OaksidePage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? Evidence from previous inspections and comments from the manager indicated a positive attitude to responding to complaints and any adverse comments, usually from family members or advocates had been formally investigated. The company had previously rewritten the complaints policy and procedure for all its homes and details of the CSCI had been included; a copy was on display in the entrance to the home.Coppice and OaksidePage 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES02 Key findings/Evidence Standard met? The manager had not attended a recent briefing offered by Social Services on Adult Protection. Training on the recognition and reporting responsibilities in relation to the abuse of vulnerable people had been provided to staff but not all had received it; the manager reported that internal training was planned for later this year. However recent experiences at the home would indicate that awareness of the issues and how to use the statutory procedures was good. A system of money management had been arranged by the company, which made cash available from the local bank the day after a request is put through to the Company HQ. The manager had previously reported that the advocate from the Derbyshire Advocacy Service was enquiring at local banks about their policies on individual bank accounts for the homes service users, but no conclusions had been reached in respect of this.Coppice and OaksidePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 4 Key findings/Evidence Standard met? The home is a purpose built environment in 2 bungalows that had been fitted out to a high design standard and offered very spacious and comfortable accommodation. The home is close to the town centre and all its amenities. Maintenance of the environment has been continued to a high standard and the services of a handyman employed at the home have helped to continue this. All bedrooms in Oakside had been redecorated in very individual styles, since the last inspection, and 2 had been fitted with new carpets.Coppice and OaksidePage 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Not specifically assessed at this visit. YES NO NO 10 0 0 0 Standard met? 0 10 03 0 0 0Coppice and OaksidePage 26 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Not specifically assessed at this visit. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Coppice and OaksidePage 27 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home was fitted with handrails and there was sufficient space in Coppice to assist with the mobility of the 3 wheelchair users. The relative of a service user present reported that all the specialised equipment needed had been supplied. Security keypads were fitted to the front door of Coppice with the code number located adjacent for staff and visitors to use.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? Although high levels of continence at the home remained this was well managed and standards of cleanliness were high.Coppice and OaksidePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? Staff spoken to during the inspection were a mixture of recent appointees and those who had worked at the home since it had opened and had brought a range of experiences to the home , both from within and outside the care sector. The staff groups for each bungalow were arranged on separate rosters, although a limited amount of crossover had occurred. The nursing qualification of the manager offered a specialised addition to the range of experience and skills within the staff group and 7 care staff had achieved qualification in NVQ2 or above. However the manager reported increasing difficulties in accessing training places for staff and the company was investigating other routes to achieve the standard. The staff and service users were observed during the inspection and healthy and positive interactions were noted.Coppice and OaksidePage 29 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 5 3 2 X 7 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 660 Nursing X X XX13 Key findings/Evidence Standard met? The levels of staff committed to the daily rota remained in excess of the previously agreed standard, and this reflected the complex needs of the service user group. There were two staff vacancies at the home and this had resulted in a moderate use of agency staff, particularly on Coppice. All staff spoken to reported that morale in the staff group was high. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The company operated an extensive selection and recruitment system that was detailed in the policy and procedure manual retained at the home. A previous examination of staff files had indicated that all required information was retained in relation to staff. It was company policy that newly appointed staff received a check by the Criminal Records Bureau (CRB) before commencing employment. Because of temporary difficulties in recruitment earlier this year, the inspector had agreed a relaxation of this requirement. This difficulty had been resolved by the time of the inspection. Copies of the code of conduct issued by the General Social Care Council (GSCC) had been distributed to staff.Coppice and OaksidePage 30 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Training records and individual training plans had been started for care staff, with the annual appraisal being the development point for this activity. Staff reported that training opportunities had continued to a good standard. New staff spoken described a structured Induction programme and the manager reported that a replacement scheme using a programme developed by The Association for Residential Care (ARC) in conjunction with LDAF was being examined by the company and a meeting to plan this was imminent. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 2 Key findings/Evidence Standard met? The manager and staff reported that supervision and consultation had continued to be achieved on an informal basis and that she continued to investigate methods of providing staff with more formal arrangements that involved group and team building processses. Annual appraisals had been commenced.Coppice and OaksidePage 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence Not specifically assessed at this visit. NO 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Coppice and OaksidePage 32 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? Not specifically assessed at this visit.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? Not specifically assessed at this visit.Coppice and OaksidePage 33 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Key aspects of servicing and health and safety practices were in order on the day of the inspection. Shortfalls in staff training remained from a previous inspection in the areas of food hygiene and infection control. The 5-year electrical wiring inspection had been carried out since the last inspection. The service of the fire alarm and emergency lighting systems was not being carried out on a routine basis on the advice of the Mantenance Manager of the company, because of the regularity of testing being carried out. Servicing was to be carried out on a needs basis. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not specifically assessed at this visit.Coppice and OaksidePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateBrian MarksSignature Signature Signature2nd November 2004Coppice and OaksidePage 35 Public reports It should be noted that all CSCI inspection reports are public documents.Coppice and OaksidePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 28 September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Coppice and Oakside Page 37 Amendments to the report were necessaryYESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 16th November 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther:NOCoppice and OaksidePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of United Health confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of United Health am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Coppice and OaksidePage 39 Coppice and Oakside / 28th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000019965.V188428.R01© This report may only be used in its entirety. 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