CARE HOME ADULTS 18-65
Coppice House Main Road Huntley Gloucestershire GL19 3DZ Lead Inspector
Tanya Harding Unannounced 10 June 2005 09:30 and 15th June 2005
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Coppice House Address Main Road Huntley Gloucestershire GL19 3DZ 01452 831196 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Orchard End Ltd Mr Bassam Adib Khali Jubrail Care Home 11 Category(ies) of LD - Learning Disability Both (11) registration, with number of places Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th October 2004 Brief Description of the Service: Coppice House is a residential care home for eleven adults with learning disabilities who may also have challenging behaviours. The home consists of the main building and an adjacent bungalow which is a few yards from the main house. Coppice House is situated approximately eight miles from Gloucester city in a rural location and is surrounded by extensive grounds. The main house accommodates seven service users, all having first floor single rooms. There are also two bathrooms and a small office on this floor. On the ground floor there is a large lounge, dining room, kitchen, laundry, office and bathroom. The bungalow accommodates four service users in single rooms. There is a lounge/diner, conservatory, kitchen and two shower rooms. Close to the main house there is a large patio and landscaped garden. Coppice House is one of four homes which are part of Orchard End Limited, a subsidiary of C.H.O.I.C.E Ltd. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection began at 9.15 and lasted about five hours. The registered manager was present for the duration of the visit. The majority of the service users were in the home. Two service users were visiting relatives for the weekend. Care plans and other documents were looked at and two members of the staff team were spoken with as part of the inspection. An additional visit was also made to the home by the Commission’s pharmacist inspector on 15th June 2005. This inspection lasted 3 hours and focused on the storage and handling of medication. Findings from both visits are presented in this report. Due the nature of the service users’ disabilities it was only possible to obtain direct feedback from one person about the care that they were receiving. Comments from the person were positive about the activities provided and relationships with staff. The person felt they would like to be more involved in the running of the home and better consulted about their views with regards to any proposed changes. All but one of the service users who were in the home during the visit were greeted and appeared well. One person was choosing to spend time on their own in their bedroom. Three comment cards were sent back to the Commission from family members and health and social care workers who know the home. Overall comments were positive and showed that the home is welcoming to relatives and provides them with the necessary information. What the service does well:
Service users’ needs are thoroughly assessed before they move into the home. There are care plans, risk assessments and behaviour management programmes in place for all service users. Service users are supported to take part in a range of different activities in groups or individually. There is a full time activities co-ordinator whose role is to arrange and provide more enjoyable and meaningful activities for the service users. Service users have a varied and balanced diet. There are some good arrangements in place to help ensure service users always receive the medicines prescribed for them and that these are stored safely. Staff have received some training to help them understand about medicines.
Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 6 Checks are carried out to make sure that only suitable staff work in the home. The training and induction programme of staff is good and relevant to the work that they do. What has improved since the last inspection? What they could do better:
Staff work in dedicated teams and comments were received suggesting that approach used by different teams lacks consistency. The manager needs to identify the cause of the difficulties and give the team guidance on how to offer service users the support they need in a consistent way. Supervisions for staff need to be more comprehensive so that any problems are picked up and sorted out as quickly as possible. This way the staff can be sure about doing their job well. Supervision and formal support for new staff is especially important but is not implemented until staff are some six weeks into their employment. Care plans, risk assessments and support programmes are on the whole quite detailed, but need to be more person-centred. The Organisation has previously expressed a commitment to introducing person centred approach. This would enable the home to meet people’s assessed needs with greater involvement and participation of the service users. Staff who need to further their skills and understanding of Total Communication must be given the necessary training. Written procedures are needed to explain to staff how medicines are to be handled in the home. Some staff could benefit from additional training about medication. Medicine records and plans for their use must always be kept up to date. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 7 Staff shortages are continuing to have detrimental effects on staff and on people living at Coppice House and this must be addressed. Floor surfaces in some rooms need to be replaced to reduce the hazard of tripping and slipping. 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 House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 9 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 standard(s) 2 and 3 People who are referred to the service and their families receive clear information to enable them to make a choice about whether or not they would like to live in the home. A long trial period is agreed so that both the service user and the home can be sure that Coppice House is the right option for that person. EVIDENCE: The Organisation has a comprehensive admissions policy in place and all new admissions are overseen by the group project manager who has skills in carrying out assessments. Prospective service users are assessed prior to admission and are offered introductory visits to the home. Placements are offered to prospective service users when the home is sure it can meet their assessed needs. Records of the most recent admission showed how the information about the needs of the service user was collated. Care plans have been developed, based on assessed needs. Some of the historical information about the person suggested that Coppice House may not be the most suitable placement due to the size of the home. The new person has to fit in with some ten existing service users, and in the past this has caused difficulties for the person. This may mean that the placement could be compromised from the start to the detriment of the new person and the existing service users. The group project manager explained that the person had a choice of living in a smaller group in the bungalow, but made a positive choice to live in the main house. This made
Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 10 the home anticipate some difficulties and they had involved support of a psychologist to help the person settle in better. Comments received from staff and examination of the records showed that there have been numerous difficulties in supporting the new resident. One service user felt unhappy and unsettled about the behaviours of the new person. Meetings have been held with the involved professionals as well as with the new service user to look for a better approach in supporting the person. The group project manager said that the team has learned from this experience and has put systems in place so that any problems with settling in can be picked up and addressed more quickly. The trial period for any new resident is 12 months as this allows more time for the person to decide whether they want to live at Coppice House as well as for the home to see whether the right kind of support can be provided. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 11 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 standard(s) 6 and 7 People living in the home may not be adequately consulted about how they want to be supported and how they can make decisions and take control over various aspects of their lives. This means that the rights of people at Coppice House may not be safeguarded at all times and staff may not be fully aware of what is important to each person. Inconsistencies of approach create confusion about how staff should be offering support and this is detrimental to the service users. EVIDENCE: Each person has a set of care plans, risk assessments and behaviour management protocols. Care plans are not person centred and do not reflect wants and aspirations of the individual service users. Goals in care plans reflect the desired outcomes identified by the staff team and not by the service user. They focus on correcting inappropriate behaviours through staff responses and behaviour management protocols. There is no emphasis on how people are supported to decrease their dependency on staff. Some information in care plans / risk assessments is actually incorrect, for example for one person who has a diagnosis of a ‘mild learning disability’ the risk assessment stated that the person had ‘severe learning disabilities’. A
Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 12 considerable amount of information and phrasing in care plans and risk assessments is repeated for different service users with the exception of changing the person’s name. Information in care plans for one person showed that at the beginning of each shift a designated staff member needs to be identified to support the service user in activities of daily living. Two staff spoken with were not aware of this requirement and said that this allocation did not take place at the beginning of the shift. Additionally one person needed a high staff ratio to access the community independently or with just one other person and again staff were unaware of this and said that the person actually went out in a group of up to six other service users. Staff members were concerned about the detrimental effects on the service users caused by different staff teams working inconsistently. The differences of approach by different team leaders became particularly evident to staff who had experienced working in one team and then needed to provide cover for another team. Examples given to the inspector showed that it was the service users who suffered the consequences of these variations in approach. For care plans and support programmes to be effective all staff must be consistent in their approach. All staff need to be aware that inconsistency may jeopardise the emotional and psychological wellbeing of the service users as well as result in escalation of challenging behaviours. There are no residents meetings or any formal ways in which service users are kept up to date with proposed changes in the home. One person said that although they get to meet new staff prior to staring employment, nobody asks them whether they liked those staff or not. One person said they would find some sort of formal exchange of information in the home useful. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 13 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 standard(s) 12, 13, and 15 People living at Coppice House take part in a range if social, educational, employment and recreational activities, which enrich their lives and enable them to be part of the wider community. Contact with relatives is encouraged to enable people living in the home to be involved in family life. EVIDENCE: An activities co-ordinator has been in post several months now and opportunities for service users to access various activities have increased. This includes accessing leisure facilities, specialist facilities as well as educational venues. One service user has a part time job. There are plans to make a more self-sufficient kitchen in the bungalow so that service users can be supported to make snacks and drinks as part of a more independent lifestyle. These plans have been talked about for a considerable period of time and to date no visible progress has been made. Implementation of the above changes would be a very positive way forward as the access to the main kitchen remains restricted and some of the service users are missing out on opportunities to maintain or develop the relevant self-help skills.
Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 14 One person said they had a busy timetable of things to do and could choose when to join in with activities offered. One person was concerned about the health of their family member. They wanted to know whether their relative was getting better and wanted someone to let them know this or to arrange a visit to see the person. This was clearly very important to the service user and efforts must be made to support the service user in making contact with the relative (as appropriate). People living at the home are supported to visit their families on regular basis. Two people were visiting their parents for the weekend at the time of the inspection. Comments received from relatives showed that they were welcomed into the home, consulted about the care of their relative and kept informed about important matters. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 15 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 standard(s) 20 Medicines are generally safely managed but more attention to details is needed in some aspects and records. There is some training for staff and assessments but this is not supported with written, up to date policies and procedures for staff to follow. This has been the situation for some time and could leave service users at risk, as staff have no written procedures defining the manner in which the company expects medication to be managed. EVIDENCE: Medicine storage arrangements were clean and tidy. Medication Administration Record (MAR) charts inspected were generally completed well and had additional information included by home staff to clarify use of medicines. Staff have received external training about the monitored dose system (MDS) and the manager carries out a medication assessment before staff undertake this task. Some staff have also completed additional college based training but this should be completed by all staff handling medication. Delegation, on an individual basis by the responsible primary health professional, is needed for administration of rectal medication by care staff who have undertaken additional training and deemed competent in this procedure. Recent medication policy and procedures are not in place in the home although being reviewed by management.
Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 16 The actual administration of medicines to individual residents may not always follow best practice guidelines when taken to rooms. Medicine cupboard keys must always be kept securely by authorised staff. Methods to allow regular audits for correct use of medicines are needed. Disposal records for all medicines must be available in the home. Information about how each resident likes to take their medicines is available but in some cases needs expansion so as to document consent to medication or administration in their best interests. Handwritten entries on the MAR charts need to be countersigned for correct transcription. There are good protocols for use of ‘as required’ medicines but in some cases additional information is needed. Where residents take medication from the home for periods of leave records must be made on the MAR chart of what has been taken and subsequently returned. An up to date BNF is needed – the manager confirmed this has been ordered. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 17 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 standard(s) 23 Challenging behaviour of some service users is putting other service users at risk of injury and emotional upset. Inconsistency of approach between different staff teams is putting the service users at an unnecessary risk of increased behavioural challenges to the detriment of the service users. Poor practices by staff are dealt with more decisively by the home than before. This is an important step towards putting across the message that inappropriate and abusive conduct will not be tolerated and protects the safety and rights of the residents. EVIDENCE: The home accommodates service users with complex behavioural and communication needs and staff receive training in diversion/ de-escalation, breakaway and physical intervention in order to respond to aggression. Some staff have attended an Abuse/ Communication course about identifying and responding to signs of abuse. Although de-escalation strategies are used to prevent and redirect violent behaviours, the use of physical intervention is still very evident for several service users. This is a very restrictive approach and could further compound the upset experienced by the individuals. There have been reports of aggressive incidents from service users who do not ordinarily display such challenges. It is possible that this is linked to the inconsistencies in how staff respond to different situations. It is also possible that people have been unsettled by the tendency of one person to scream continuously for a period of time and to attack / threaten others in the home. Although such attacks are mainly directed at staff, there have been incidents when other service users have been targeted. The behaviour management
Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 18 strategies seen on file are very detailed, however, as some staff are not fully aware of these, these strategies may not always be followed. The manager needs to be confident that the whole of the staff team are very clear about how they need to support individuals who display violent behaviours in order to make sure other service users do not suffer as a result. The home holds regular meetings with the Community Learning Disabilities Team about managing difficult behaviours. The home also informs relatives and placing authorities when a service user has been injured, mistreated or unwell. This is important to enable people outside of the home to advocate on behalf of the service users if they have concerns about their care and wellbeing. Feedback from relatives and outside professionals should be sought and recorded as necessary. Reports of poor or abusive practices by staff are thoroughly investigated by the Organisation and formal action is taken in line with the Protection of Vulnerable Adults procedures and the employment legislation. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 19 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 standard(s) 24 Some positive improvements have been made to the environment and plans to provide two separate living areas in the main house should provide even more options for where and how service users want to spend their time. EVIDENCE: Plans are progressing with regards to dividing the main living room into two separate lounges. This will offer people a quite area and an activity area. At the time of the inspection the dining room floor had been ripped up in several areas. It was quite unsightly as well as hazardous. It was replaced shortly after the visit with a more welcoming wood effect flooring. The slippery floor in the ground floor shower room also needs to be replaced with a more suitable covering. A detailed inspection of the environment was not carried out on this occasion, but the home does have a continual programme of maintenance in place undertaken by maintenance personnel. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 , 35 and 36 Robust recruitment policy and practice protects service users from unsuitable carers being employed. However, ongoing staff shortages are putting pressure on the teams and limiting the opportunities for service users. A co-ordinated programme of induction, foundation and NVQ’s is in place to ensure that all staff receive the basic level of training to supplement and develop their skills for the benefit of service users. Formal supervision of all staff is being better monitored by the home manager, but needs to happen regularly and be more relevant to the work staff are expected to perform. EVIDENCE: The home requires a minimum of seven staff on duty during the day when a full compliment of service users is in place. Since February 2005 there have been 10 service users in the home. Rotas for April and May 2005 show that some shifts were covered by only 4 staff, some by 5 staff and other shifts by 6/7 staff. The recruitment is happening. Two new staff have started and one is hoping to start shortly. This will leave the home with another 3 vacancies, which at present are being covered by existing staff doing overtime and staff from other homes in the group providing cover. Staff shortages in the home have a direct impact on the opportunities service users have to access community facilities. This is because the home is in a very rural area and also some service users have high supervision needs when out and about. The
Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 21 effects of staff shortages on the people living in the home need to be better monitored to provide a better overview of how this impact on the quality of the service provided. The Commission has been concerned about the staffing levels in the home for sometime and will take enforcement action unless a consistent improvement is seen. Staff files for three new members of staff confirmed that they are being appointed after receipt of the necessary information and checks. This includes the full employment history, at least two references, health questionnaires, evidence of identity and disclosure of convictions. The manager has on occasion commenced staff in employment before their CRB was received. Where this has happened, a PovaFirst check has been obtained and the Commission notified. The home employs a day care co-ordinator as well as a full time cook, which alleviates some pressures on the care staff. Both roles are much appreciated in the home. Each designated team has a team leader in place. Two of the team leaders have achieved NVQ3 and have commenced the NVQ4 in care. The other two team leaders have started NVQ3. All care staff are put through induction and foundation training. Two staff have completed NVQ2 and further two staff have commenced their NVQ2. This means that the home with its 21 strong staff team is making good progress towards achieving the Government set target of 50 staff achieving NVQ level 2 or above by 2006. Many service users have significant communication difficulties but the use of Total Communication approaches could not be observed to any significant extent. There is a board with photographs of the staff who are on duty and some reference in care plans as to signs / actions used by some people to communicate their basic needs. The home manager must carry out an audit of staff skills in the area of Communication and access the relevant training for those staff who are lacking knowledge in this area. This shortfall in staff skills has been identified in previous inspections. Records are being maintained of when team leaders carry out formal supervision sessions with the care staff. In some cases supervisions have not taken place on regular basis with gaps of several months between meetings. The function of these sessions is to monitor staff practice through discussion about roles and responsibilities, identifying shortfalls in skills and knowledge and providing feedback to staff members on how well they work. However, these areas were not always sufficiently covered. The manager needs to ensure that supervisions for staff are carried out at appropriate intervals and are comprehensive. Supervision and formal support for new staff is especially important but is not implemented until staff are some six weeks into their employment. Review of this process is recommended. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: The Organisation continues to carry out regular and very thorough checks on all aspects of the service provided at Coppice House. This is done through Regulation 26 visits as well as care reviews. Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 23 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 3 x x Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 2 x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 2 x x Standard No 31 32 33 34 35 36 Score x x 2 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Coppice House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 6 6 Regulation 17 15 Requirement Information in care plans and other records kept for service users must be factually correct Care plans must demostrate that people have been consulted about what is important to them and distinguish between the aspirations of the individual and expectations of others Agreed care plans, risk assessments and other support protocols must be adhered to and implemented consistently by all staff. Where there is a discrepancy between what is written in care plans and what is done in practice, this must be reviewed and revised guidance re-issued / clarified to all staff. (A requirement to ensure that staff have good knowledge and understanding of agreed care plans has not been met by the original timescale of 31st December 2004) Systems must be in place to formally seek views of service users in the way which is meaningful to each individual Support a specific indivudual to make contact with their parent Timescale for action 30st September 2005 31st October 2005 3. 6 13(6) 31st August 2005 4. 8 12 31st October 2005 31st August 2005
Page 25 5. 15 12 Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 as appropriate 6. 20 18(1) All staff handling and administering medication to receive additional accredited training in the safe handling of medicines. A written medication policy and procedures to be in place. This to be reviewed with the latest guidelines from the Royal Pharmaceutical Society of Great Britain to cover all aspects of the handling of medicines specifically for this home. A copy to be forwarded to the Commission. All staff to be made aware of the policy, to receive training and ongoing monitoring of their adherence to it. Medication administration procedures to be reviewed to ensure the best practice in the Royal Pharmaceutical Society of Great Britain guidelines is always followed with medication being administered, in a secure manner, directly to the service user from the container in which dispensed by the pharmacist and with immediate reference to the MAR chart. Medicine cupboard keys always to be held securely by authorised staff. Regular audits to be conducted to demonstrate correct use of medicines and staff competence in administration and recording of medicines. ·Full records for the disposal of all medicines to kept and available in the home. Records to be kept of medication taken and returned during periods of leave from the home Handwritten additions on the MAR charts to be countersigned by a second authorised staff 30th September 2005 31st July 2005 7. 20 13(2) 8. 20 13(2) 31st July 2005 9. 10. 20 20 13(2) 13(2) 15/06/05 31st July 2005 11. 20 13(2) 17(1) 15/06/05. 12. 20 13(2) 31st July 2005
Page 26 Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 13. 20 13(2) 17(1) 14. 23 13(6) 15. 16. 24 35 23 18 member as a check for correct transcription. Protocols for ‘as required’ medication to be updated to include information where variable doses are prescribed and for any medicine prescribed in this way. All staff must be clear about how to respond to violent or other behaviours appropriately and in accordance with agreed behaviour management plans Non-slip flooring must be provided in the shower room Staff require further skills and development in the area of Total Communication and relevant training must be provided. (Previously a requirement was issued to implement a strategy for the home to include identification of skills and training in this area by 31st December 2004. This was not met) Formal and recorded supervisions for staff must be more comprehensive and demonstrate that practice issues have been discussed, any shortfalls identifed and action taken in response to these There must be sufficient staff on duty at all times. Where this is not possible, a record must be kept of what efforts were made to summon extra staff and how the staff shortage affected the opportunities for the service users during a particular shift.. 31st July 2005 31st August 2005 31st October 2005 31st December 2005 17. 36 18 30th September 2005 18. 33 18 30th September 2005 Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 6 20 20 23 36 Good Practice Recommendations Person centred planning with the use of Total Communication strategies should be used for all service users with comminication needs All containers of medicines (other than those supplied in the MDS blisters) to be dated on opening. An up to date edition of the British National Formulary to be kept in the home. Feedback from relatives and involved professionals about care provided should be sought and recorded Formal supervisions / work reviews for new staff should be carried out with greater frequency in the first few months of their employment Coppice House D51_D03_S55593_CoppiceHse_232125_100605_Stage4_U.doc Version 1.30 Page 28 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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