Inspection on 07/11/05 for Coppice and Oakside

This inspection was carried out on 7th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coppice and Oakside 30/10/08

Coppice and Oakside 02/11/06

Coppice and Oakside 20/04/05

Coppice and Oakside 28/09/04

Coppice and Oakside 21/04/04

Coppice and Oakside 13/11/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Coppice and Oakside Shipley Common Lane Off Heanor Road Ilkeston Derbyshire DE7 8TS Lead Inspector Brian Marks Unannounced Inspection 7th November 2005 11:30 Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 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 Coppice and Oakside DS0000019965.V264495.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 Adults 18-65. 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. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coppice and Oakside Address Shipley Common Lane Off Heanor Road Ilkeston Derbyshire DE7 8TS (0115) 9329603 01159443690 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) United Health Limited Ms Marion Rosalind Atherton Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two Units - one manager Oakside - be occuppied by a maximum of 4 service users Coppice - be occuppied by a maximum of 6 service users 20th April 2005 Date of last inspection Brief Description of the Service: 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 closure 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 residents 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 Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a morning. Additionally, time was spent in preparation for the visit, looking at previous reports and other documents. Apart from examining documents, care files and records, time was spent looking around the home and speaking to staff who were on duty and to the manager. Because the residents of Coppice have a lot of difficulties expressing themselves in words, they were not able to contribute directly to the inspection process, but they were observed throughout the visit working with and being cared for by staff. The residents who were present in Oakside were able to speak for themselves with some support from staff. The parents of one of the residents of Coppice were present during the inspection visit and gave their views on the care of their daughter at the home. An important activity of inspection is the careful examination of residents’ individual care records, and 2 were selected for this purpose. The aim of inspection activity during the current inspection year is to assess a service against the ‘key’ National Minimum Standards and these are identified at the beginning of each section of the report. The majority of these keys standards were examined at the last inspection so, for a more complete picture of this service, this report should be read in conjunction with the report dated 20th April 2005. What the service does well: The staff are a committed group of people and they work hard to make the home a happy and safe environment for the residents to live in. Because they work successfully as a team, the staff are able to deal with difficulties around the home in a calm and consistent way; they are also assisted to do this by the new manager. Staff are helped to care for the residents successfully by a good system of documents and records, including clear care plans that identify the problems faced by residents. The home itself was opened only a few years ago and was built with the present group of residents in mind. All of the rooms are large and have been fitted out with good quality furniture and furnishings. Equipment has been provided to help staff care for people who have difficulty moving around, and this is particularly true in the bathrooms which have had a lot of money spent on their fixtures and fittings. Standards of decoration of the home are good. Staff have made efforts to provide interesting and stimulating activities, including holidays, for the residents and because the home has a lot of staff on duty they are able to go on outings and to have individual 1-to-1 time making good use of local facilities. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: 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. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will 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. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents’ needs are met through a system of assessment, carried out both before and after coming to the home, that form the basis of the way staff care for them in consistent and individual ways. EVIDENCE: Information received from previous inspections and from the examination of case files indicated that residents had extensive assessments of their requirements carried out before they came to the home, although none had done so recently. Since the last inspection the home’s senior staff have carried out a reassessment of all residents and the problems they face and this has led to programmes of care being planned from up-to-date information. Additionally the care records indicated that these programmes of care (care plans) were being looked at further – ‘fine-tuned’ – on a monthly basis. The case files examined also had documents from the care managers and health care professionals who became involved after the residents had settled at the home, indicating that the difficulties faced by the residents had continued to be examined by people outside the home. All of these documents are individual to the resident concerned and are very comprehensive in their content Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. 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. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Detailed individual care plans have been developed at the home so that support can be given consistently and in safety. These include a system of documentation for the management of risk areas that contribute to overall safety of residents. EVIDENCE: Examination of care records indicated that residents have an individual plan of care, which includes aspects of personal and health care activity specific to the individual concerned and linked to a range of ‘risk assessments’. As noted above the care plans have been revised and updated since the last inspection, and the manager agreed that this had improved the levels of consistency of work being planned and carried out. As noted above, the care plans had been reviewed on a regular basis, as had been required at the last inspection. Staff commented that they were more involved with the care planning process than before and all contributions were valued. The manager commented that with some residents there were still some difficulties with the involvement of care managers and other key people from outside the home in meetings arranged to look at resident care. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 10 Some elements of the care plans include risk assessments, which indicate key areas of concern and ways in which staff can minimise or eliminate any problems. This was carried out to ensure individuals did not come to harm, and to guide staff in safe ways of working. Examples of the problem areas covered included difficult behaviours and agitation, weight loss and pain relief. For the assessment of the other key standard see the inspection report dated 20 April 2005. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. 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. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 17 Residents are assisted to enjoy the facilities of their wider community and a wider social life, and also to enjoy a varied and healthy diet that is based on their preferences and individual needs. EVIDENCE: It was noted from the activity records and from daily log sheets that the 2 vehicles at the home were used every day to give residents 1-to-1 experiences with staff outside the home, and on the day of the inspection 2 were on a shopping trip to Derby. Residents also enjoy meals at local pubs and restaurants and go further afield, in small groups, at the weekends to enjoy the countryside and local beauty spots. In this way they enjoy experiences of their local community and a wider social life. Residents from Oakside also attend a local day centre and other social groups, and a resident from Coppice attends a local college for special education. Examination of the menus at the home and discussion with the member of staff preparing lunch indicated that a planned approach to the provision of a suitable diet is made at the home. The menu is prepared on a weekly basis, but a new set of menus, based on fresh foods and healthy eating, was due for imminent introduction. The member of staff preparing the new menus had Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 12 also prepared recipe sheets to help staff and improve consistency. Because a number of residents are regularly out of the home the main meal of the day is the evening meal, and a light breakfast is offered with a cooked option available at lunchtime for those who are at home; drinks are available throughout the day. Individual resident preferences and eating difficulties, are worked into the menu plan, and incorporate both the traditional and modern in style to reflect those preferences. Fresh ingredients were in evidence in the kitchen and good stocks are maintained through regular food shopping, carried out locally by the care staff with some help from the residents. Specific health needs are reflected within the catering arrangements, such as both weight loss and gain, and one resident requires softened foods in order to maintain good diet management. The residents take all their meals together in the dining room and staff were observed giving direct assistance to those that needed it over the lunch period. For the assessment of the other key standards see the inspection report dated 20 April 2005. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. 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 home’s 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. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not specifically looked at this inspection; for the full assessment of the key standards see the inspection report dated 20 April 2005. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a comprehensive complaints policy and procedure and most of the residents have their interests supported by outside professionals and family members. Protection of residents has been improved by staff training opportunities. EVIDENCE: The home has a comprehensive complaints policy and procedure that has been centrally developed by the company and regularly updated. A copy of the policy is included in the Service Users Guide, which is given to residents and their representatives, and a summary is also on display at the home. The manager reported that there had been no formal complaints made by anyone within the past 12 months but details of a number of informal problems were included in the home’s complaints record, and the manager or deputy had resolved these. Because some of the residents had a background with Aston Hall Hospital, there had been some involvement with the advocacy service linked to its closure. This had been particularly useful because not all residents had independent involvement of outside professionals or family members. An assessment of the home against Standard 23 was made at the last inspection and since that time all staff, apart those recently recruited, had had the opportunity to take part in a video-based training activity on the subject of adult protection, so that awareness of this has improved among the staff group. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. 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. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The home is equipped, furnished and maintained to a high standard and offers homely and spacious facilities for residents to enjoy. EVIDENCE: The home was built specifically for this group of residents, and its corridors and rooms are large. It was supplied with a good range of equipment, furniture and fittings of a style that could be expected in an ordinary domestic setting. Security against both intruders coming in, and residents going into unsafe places or wandering off, is covered by a keypad system in Coppice, and a routinely-locked front door in Oakside. The home is near the town centre of Ilkeston and the home’s transport offers good access to local amenities. The improvement programme of the home has been continued with 1 of the bedrooms being prepared for refurnishing with fitted units during the inspection visit and the 3-piece suite in Oakside replaced since the last inspection. The home continues to benefit from the services of a maintenance person who ensures that all repairs are completed quickly and who is also responsible for a number of health and safety activities. The home has a well-equipped laundry, with care staff responsible for the personal laundry and bedding of residents. Standards of cleanliness and hygiene were high at the time of the inspection Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 16 Because of the high standard of the environment of the home these 2 standards are scored as 4. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. 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 home’s 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. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 EVIDENCE: These standards were not specifically looked at this inspection, other than to establish from the examination of the manager’s records and staff personnel files that a system of 1-to-1 supervision meetings for all staff has been reestablished; these should take place every 2 months. For the full assessment of these key standards see the inspection report dated 20 April 2005. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. 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 home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42 The home is well managed by the newly appointed manager but she has not yet been registered with the CSCI, which is required by law. Safety of the home had been improved through servicing and maintenance activities and specific aspects of staff training, but these processes are not yet complete. EVIDENCE: The deputy manager of the home has been promoted to the post of manager, a vacancy that was created in September of this year, and staff comments would indicate that this has been a popular development. She is currently completing a Registered Manager’s Award (NVQ level 4) and has extensive experience of working with the residents of this home and with people with similar disabilities. She had not applied to register with the CSCI at the time of the inspection as is required by the law. From examination of the records and administration systems of the home the majority of key activities related to health and safety at the home had been carried out. However there were shortfalls in some areas that limit the overall protection of residents and staff: Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 19 Fire drills and fire safety training need to be completed for all staff, as well as core training in food hygiene and moving and handling for all recently appointed staff. The gas equipment has not been serviced for some time. The Fire Officer has not carried out an inspection at the home for some time. Coppice and Oakside DS0000019965.V264495.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X X X X X 4 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coppice and Oakside Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000019965.V264495.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 YA23 Regulation 13(6), 18(1) Requirement All staff must receive training in their responsibilities in relation to the protection of vulnerable adults. (Previous timescale of 20/04/05 not met). The manager must consult with the Fire Officer about the need for an inspection of the home. The target of 50 of all care staff achieving an NVQ at a minimum of level 2 must be complied with by the due date. The manager must apply to register with the Commission for Social Care Inspection. The manager of the home must achieve an NVQ in management and care at level 4 by the due date. 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. (Previous timescale of 30/06/05 not met). All staff must receive instruction in food hygiene and infection control. (Previous timescale of 20/04/05 not met). The registered person must DS0000019965.V264495.R01.S.doc Timescale for action 31/03/06 2. 3. YA24 YA32 23(4) 18(1), 19(5) Care Standards 2000 9(2) 31/12/05 31/12/05 4. 5. YA37 YA37 31/12/05 30/06/06 6. YA42 18(1), 23(4) 30/03/06 7. YA42 13(3), 18(1) 13(4), 30/03/06 8. YA42 31/01/06 Page 22 Coppice and Oakside Version 5.0 18(1), 23(4) 9. YA42 23(2) ensure that fire drills involving staff and residents are carried out periodically at the home. The registered person must arrange for the servicing of all gas equipment at the home and forward a copy of the certificate to CSCI for examination. 31/01/06 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. Refer to Standard YA35 YA35 Good Practice Recommendations Any training provided to staff, including induction and foundation training, should be provided in line with Learning Disability Award Framework (LDAF) standards. The registered person should structure staff training needs into individual plans that reflects the care activities carried on at the home. Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Coppice and Oakside DS0000019965.V264495.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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