Inspection on 10/05/07 for Coppice House

This inspection was carried out on 10th May 2007.

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

The inspector 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coppice House 21/11/06

Coppice House 06/06/06

Coppice House 30/11/05

Coppice House 10/06/05

Coppice House 08/10/04

Coppice House 01/05/04

Coppice House 23/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Coppice House Main Road Huntley Glos GL19 3DZ Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 10th May 2007 14.00 Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 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 House DS0000055593.V332895.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 House DS0000055593.V332895.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coppice House Address Main Road Huntley Glos GL19 3DZ 01452 831196 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) www.orchardendltd.co.uk Orchard End Limited John Evans Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Coppice House is a residential care home for eleven adults with learning disabilities who may also have autism and challenging behaviours. People living at the home have complex needs particularly in relation to communication. The home consists of the main building and an adjacent bungalow that 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. Coppice House is one of six registered homes that are part of Orchard End Limited, a subsidiary of C.H.O.I.C.E Ltd. The home has a Statement of Purpose and Service User Guide that are available from the office or head office of the organisation upon request. Each person has a contract including terms and conditions and a summary of the Statement of Purpose. Inspection reports for the service are kept in the office. Fee levels for the home range from £1376.00 to £2264 per week. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in May 2007 and included two visits to the home on 10th and 11th May. The registered manager was present throughout and the group manager was present for feedback. Time was spent observing the care of one person for a period of two hours. The care being provided to three people was examined in depth that included speaking to them, observing their care and reading records relating to them. Five staff were spoken to about the care they provide. Comment cards were received from one person living at the home, five members of staff and two health care professionals. A pre-inspection questionnaire was returned prior to the inspection and regulation 26 reports also provided additional evidence. What the service does well: What has improved since the last inspection? Each person has a person centred plan that they are being involved in developing. People are developing positive relationships with staff. They were observed being treated with sensitivity and respect. People were being offered choices about their day-to-day lives. Some staff were using makaton sign language to help people with limited verbal expression to communicate their needs. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 6 Health action plans are being put in place. There has been a significant reduction in the use of physical intervention. Staff confirmed that they are using diffusion and de-escalation more effectively and would use physical intervention as a last resort. Improvements to the environment include replacing the carpet in the lounge, providing new sofas and chairs and replacing the floor in the kitchens and shower room. Recruitment and selection procedures have significantly improved safeguarding people from possible harm. 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. The summary of this inspection report can be made available in other formats on request. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 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 House DS0000055593.V332895.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to the information they need which is regularly reviewed enabling them to make a decision about whether they wish to live at the home. An assessment of their needs and wishes are taken into consideration before offering them a place. EVIDENCE: The registered manager confirmed that the Statement of Purpose and Service User Guide would be reviewed on an annual basis. Amendments were made to these documents to reflect changes to the service. He confirmed that copies would be placed on peoples’ files. The home has three vacancies. The registered manager confirmed that they have had several referrals. Copies of care plans and assessments received from placing authorities were available for inspection. The registered manager confirmed that visits to the home had been arranged and that the management team would complete an assessment of the person’s needs if they felt the application could be processed further. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A person centred approach to care planning is enabling people to take control of their lives. People’s needs are being assessed and they are being supported to makes decisions about their lifestyles. Risks are being managed safeguarding people from possible harm. Improving access to information for those with limited communication will ensure they are involved in these processes. EVIDENCE: Person centred plans have been put in place for all people living at the home. This process included people living in the home and those involved in their care discussing their wishes and assessed needs. From this a plan has been put together describing each person’s likes and dislikes, support guidelines, goals for the next six months and risk assessments. People sign their plans where appropriate. Plans also have a section dedicated to Autistic Spectrum Disorder and how this affects each person. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 10 Each part of the plan clearly links to other areas. For instance where a hazard is identified in one of the goals records refer the reader to the relevant risk assessment. A summary of identified risks is then further explored within risk management plans. Plans and risk assessments had been regularly reviewed and there was evidence of annual reviews with the placing authority, some of which supply a copy of their assessment and care plan. Where changes to need are identified key workers make comments on the relevant section on the care plan. The organisation’s assistant psychologist and the manager confirmed that they then review the plans. Copies of several plans and risk assessments that had recently been reviewed in this way were available for examination. Risk assessments for people with epilepsy did not appear to give any guidance on how to minimise risks when people are having a bath or using transport. Discussions with staff confirmed that they have a good understanding of the needs of the people they support. Staff were observed supporting people in line with their identified needs such as prompting a person to use the toilet before they had a drink and interacting with another person every ten minutes to discourage them from going to sleep. The plan in relation to this latter issue did not explain why this is in place. Discussion with staff confirmed that a disrupted sleep pattern develops if the person sleeps during the day, which then may result in challenging behaviour either during the day or at night. The registered manager stated that further amendments would be made to the plans to provide clearer information to staff. Better use was observed of makaton sign language with one person and they responded in sign. The same person was observed being given an informed choice about which drink they would like to have by offering them jugs containing two different drinks. There is good use around the home of photographs and symbols. A notice board gives people a photographic version of the staff rota for the day and people were observed taking an interest in this and commenting if a mistake had been made. Another person has their timetable for the day displayed in symbol. The home continues to work closely with a Speech and Language Therapist. The registered manager confirmed that training has been arranged for staff and people living at the home to explore methods of communication appropriate for each person that may include makaton sign language, objects of reference or photograph. A communication profile will then replace the profiles currently being used. Any restrictions to freedom or choice are recorded with the reasons for these. For instance some people do not use keys or have access to the kitchen. A listening device is being used to monitor whether a person has seizures during the night. The registered manager described the process that is in place to Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 11 ensure the dignity and respect of the person. There is no protocol or guidance in place on the person’s file in relation to this. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. EVIDENCE: Each person has an activity schedule with a range of activities including college, swimming, horse riding, ten pin bowling, shopping and going to the pub. Massage sessions are provided at home and people can also participate in pottery sessions. Daily diaries keep a record of activities completed and occasional reference is made to the fact that people have been offered an activity and have refused to participate. It appears that some people have access to lots of activities in the community and a few spend a considerable amount of time at home. The registered manager confirmed that an activities Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 13 co-ordinator has been appointed and that there are plans to convert a large sun house into an arts and craft studio. People were also observed using a sensory room and computer room during the visits. Some staff were observed spending time with people in a positive and constructive manner including them in activities and providing them with choice about what they would like to do. For instance one person was helped to choose a video and another was given a puzzle. Some staff appeared to have difficulty knowing how to support people who cannot express their needs verbally. The registered manager confirmed that an occupational therapist would be working with the team to develop appropriate activities. Staff indicated that the staffing levels have improved and that they have no concerns about their ability to support people to access activities. They said that people have access to two people carriers and sufficient drivers. People were also observed walking to the local garage/shop and pub. People are supported to maintain contact with family and friends. Staff may need to support people to visit their family by taking them and staying with them during the visit. Diaries confirmed that family also visit the home and that one person is supported to write to members of their family. Routines within the home are flexible and dictated mostly by peoples’ day-today commitments. People were observed choosing where to spend their time making good use of the communal areas and gardens. People were observed helping to clear away after meals and helping to tidy communal areas. One person helps to clean communal areas for which he receives a weekly payment. A person was observed feeding himself and another person was observed eating their meals at the dining table, providing evidence that staff are maintaining and building on improvements noted at the last inspection. The home employs a cook to prepare the main meal of the day. She was not present during the visits. The registered manager confirmed that she has attended the ‘safer food better business’ course and has implemented their recommendations. Good food hygiene practice was observed in her absence with temperatures being recorded for fridges, freezers and hot food. Food in fridges was also labelled with the date of preparing or opening. Meals prepared during the visits included sausage, mash and fresh vegetables, ham and cheese salad and smoked mackerel risotto. Menu records confirmed that alternatives are provided. Menu sheets indicated that each person chooses a meal providing a varied and nutritional diet. The kitchen in the bungalow has been fitted with a new cooker to enable people living there to prepare their own meals. Meals were observed being taken from the main house to the bungalow. At the time of the visit they were not covered. The registered manager confirmed that the plates are normally covered in transit. The home has recently had a satisfactory visit from environmental health. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care which people receive is based on their individual needs, observing the principles of dignity, respect and privacy. Minor shortfalls in the administration of medication mean that people are not being protected from possible harm. EVIDENCE: The way in which people would like to be supported is recorded in their plans. Discussions with staff confirmed their understanding of the needs of people living at the home. For instance one person likes to have a bath and then go for a walk to the garage and another person is supported to keep a supply of cheap t-shirts because they tend to shred their clothes. People have access to hairdressing and chiropody in the home. Some people have this provided in their room or the sensory room. The registered manager said that where people prefer to stay in the lounge privacy screens are used. As mentioned the home is working with a Speech and Language Therapist to review systems within the home enabling people with limited speech to express their needs and wishes. Comments from healthcare professionals Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 15 confirmed that the home is working closely with the local Community Learning Disability Team to improve the standards of care received by people living at the home. They previously had concerns that their recommendations were not being implemented by the staff team but indicate that this is no longer the case. The registered manager confirmed that people have annual ‘OK Health Checks’. Records of healthcare appointments are being kept including refusals by people to attend appointments. For example there was evidence that one person had recently seen a dentist but had refused an optician’s appointment. The registered manager said that the team are considering alternative ways of supporting people to access healthcare professionals in these situations. Health action plans are being put in place. Those sampled indicated that information is still being collated. The registered manager confirmed that the home is negotiating with their local surgery about their input into the plans. The registered manager described the ways in which he had been trying to obtain training for staff in the administration of rectal diazepam. In the absence of training the protocol confirms that staff summon the ambulance if the person is having a prolonged seizure. Staff confirmed their understanding of this procedure. Discussions with the registered manager about the high use of medication for constipation indicated that the continence nurse is reviewing this for some people. Examination of medication administration systems indicated that they are satisfactory. A signature list is in place identifying staff that can give medication. Staff receive training in the safe handling of medication. A thermometer had just been put in place monitoring the temperature of the drugs cabinet and records will be kept. Patient information leaflets are in place. Protocols have been drawn up for ‘as necessary’ medication. There has been a change to the protocol to ensure that this medication is being given as a last resort when it is used to manage challenging behaviour. The use of this medication for one person is being monitored by a healthcare professional. Records are being maintained. There was no evidence on the medication administration record that the stock levels of this medication are being monitored. Medications are labelled with the date of opening and a list of expiry dates for drugs is kept. The medication administration record was satisfactory except for two omissions. A note on the record verified that the team leader on duty had contacted the home to confirm that they had forgotten to sign the record and that the medication had been given. A recent regulation 26 report indicated that a new drugs cabinet was being purchased. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure that is produced in a format appropriate to the needs of people living at the home. Those spoken with said they would talk to staff about any concerns they may have. Other people have regular contact with healthcare professionals and their family who would express concerns on their behalf. The registered manager said that he has received one complaint since the last inspection and this was resolved to the satisfaction of the complainant. A record of the complaint and outcome was examined. Other concerns had been expressed to him and he has responded to these immediately. He has not kept a record of these. We have previously had concerns about the sustained and high use of physical intervention at the home. Over the past six months there has been a significant reduction in the use of physical intervention. This was confirmed by staff who say it is now used as last resort if diffusion and de-escalation have failed. Staff were observed using the latter effectively during the visits. Staff continue to receive training in the Management of Response to Emotion (MORE) and have received supplementary training to provide them with alternative forms of physical intervention for use with one person. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 17 Comprehensive records are maintained for all incidents at the home and we have been informed when physical intervention has been used. A team leader was observed checking and balancing peoples’ personal finances. She explained that checks are now carried out each morning, at handover and each evening, as well as when money is withdrawn. Receipts for purchases are cross-referenced with records. People have a savings account for which a statement is kept. These records are signed and dated as they are checked. Orchard End supplies each person with a statement of their personal account with the organisation and the registered manager said these are reconciled with records in the home. There was no evidence of this on the statement. Discussions with staff confirmed their understanding and awareness of abuse. New staff have training in the safeguarding of adults during their Learning Disability Award Framework Foundation Course and NVQ Awards. Staff who have worked for the home over four years said that they had not had any recent training in abuse. The registered manager has provided copies of the ‘alerters guide’ produced by the local adult protection team. Staff confirmed that they had been asked to read the home’s policy and procedure on safeguarding adults. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is safe, clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements. EVIDENCE: Coppice House provides spacious accommodation in two buildings. Three people can live in the bungalow that has benefited from a redecoration of the conservatory and lounge, replacing the floor in the shower room and refitting of the kitchen. Areas of the main house have been redecorated including peoples’ rooms, the hallways and the kitchen. A new carpet has been fitted in the lounge and new fixtures and fittings provided. The kitchen floor has been replaced. There are plans to make further renovations to this room to ensure that a safe environment is provided. Areas of the home do not have curtains. Alternatives have been researched and the registered manager is planning to put curtains with Velcro fixings in communal areas. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 19 People have access to a sensory room, computer room and large grounds. They will also be able to use a new arts and crafts facility in the grounds of the home. There are also plans to change a bathroom on the first floor into a separate shower room with toilet and a bathroom. All bathrooms now have privacy lights outside which indicate when someone is using the room who may not have locked the door. Staff mentioned concerns about the safety of the gravel paths and driveways. The registered manager confirmed that he has asked for parts of this area to be covered in tarmac. Inventories that are in place do not appear to have been updated. At the time of the visits the home was clean and tidy. Hazardous products were being stored securely and COSHH data sheets in place. The home previously had a housekeeper but this person has not been replaced. Staff undertake the cleaning duties and are supported by people living at the home. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People benefit from having a staff team who understand their roles and responsibilities. Access to training provides them with the opportunity to acquire the skills and knowledge relevant to the needs of people living at the home. Recruitment procedures safeguard people from possible harm. EVIDENCE: The registered manager confirmed that the home is fully staffed at present. Three new staff have been appointed since the last inspection. New staff spoken with confirmed that they complete an induction course, followed by the Learning Disability Award Framework Foundation. The registered manager confirmed that candidates for NVQ Awards are presently being re-registered, eight people are completing their awards and 25 of the team have an award. Discussions with the staff team confirmed they have a range of knowledge and skills appropriate to support people living at the home. Some staff were observed using sign language and objects of reference to communicate with people. Staff were observed using diffusion and distraction techniques to support people to manage their emotions. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 21 Staff indicated that morale within the home has improved, that communication systems are getting better and that they feel supported by the management team. Several staff indicated that they have concerns about the performance of some of their colleagues. Discussions with the management team confirmed that they are aware of these concerns and working to resolve them. Satisfactory recruitment and selection practices were observed to be in place. Each person completes an application form. Where a full employment history has not been provided there is evidence that this is being requested. Two references are being requested and the reason for leaving any former positions working with adults or children is being obtained. The registered manager stated that he had appointed one person on the strength of a telephone reference from their current employer (not a care position) and that this was eventually backed up by a written reference. He stated that he did this because he had difficulty obtaining this reference before appointment. A third reference from a former care position is also being obtained. A copy of this was obtained from the central human resources department during the visits. The registered manager also occasionally verbally checks other references. Comprehensive training systems are in place which provide staff with mandatory training. A training matrix was supplied prior to the inspection. Copies of certificates of attendance are kept on staff files. The registered manager confirmed that training in the Mental Capacity Act has been scheduled for managers and team leaders in June and that epilepsy training is being arranged. A team leader is completing a course on Autistic Spectrum Disorder. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. Effective quality assurance systems are in place involving people who live at the home. Amendments to fire risk assessments will ensure that the health, safety and welfare of people is promoted and protected. EVIDENCE: Since the last inspection the manager has been confirmed by us as the registered manager for the home. He has the Registered Managers Award and completed a professional development programme with his previous employers. Staff confirmed that he is open, approachable and leads by example as a positive role model to the team. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 23 The registered manager has a clear developmental plan for the home and with the management team is striving to improve standards of care within the home. He has shown a willingness to work with us to achieve this. Quality assurance systems are in place which involve people living at the home. They took part in a survey last year which formed part of the annual developmental plan for the home. A copy of this was forwarded to us. The home also completed an internal health and safety audit last year. Each month unannounced monthly visits are completed by the group manager and a record of this visit is sent to the Commission. Staff have delegated responsibility for some of the health and safety systems within the home. They have received the appropriate training. Records are regularly completed monitoring fire systems and equipment and water temperatures. The pre-inspection questionnaire indicated that equipment and systems are regularly serviced. This was confirmed by certificates in the home. The fire risk assessment has been reviewed and the management team are presently completing an exercise with other homes to ensure a consistent approach in all local homes to fire safety. The registered manager must ensure that individual risk assessments which refer to a ‘stay put’ procedure for some people are reviewed in light of the Regulatory Reform (Fire Safety) Order 2005. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 25 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. Standard YA9 Regulation 13(4) Requirement Timescale for action 30/06/07 2. YA20 3. YA35 4. YA42 People who have epilepsy must be assessed for the risk they present when bathing or using the transport and action taken to minimise any identified risk. 13(2) Stock levels of ‘as necessary’ 30/06/07 medication must be recorded to minimise the risk of error or abuse of medication. 18(1)(c)(i) The registered person shall 31/07/07 ensure that persons employed to work at the care home receive (i) training appropriate to the work they perform including structured induction training. (In relation to the communication needs of service users.) This timescale has been repeated from the previous inspection. Training is being arranged. 23(4A) People should have a risk 30/06/07 assessment, in line with current legislation, which identifies how risks to them are minimised in the event of fire. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 26 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. 6. 7. Refer to Standard YA6 YA7 YA12 YA17 YA23 YA23 YA24 Good Practice Recommendations Where plans state a course of action to be taken by staff, the reasons for this should be included in the plan. Where listening monitors are used a protocol should be put in place describing when this can be used and that the person has consented to this. When people refuse to take part in educational or recreational activities this should be recorded in their daily diary. When hot meals are transported across to the bungalow, the plate should be covered to retain the temperature of the meal and to prevent cross infection. The person checking and reconciling financial statements should sign and date these records. Staff understanding and awareness of the safeguarding of adults should be maintained to prevent placing people at the risk of harm. Inventories should be kept up to date. Coppice House DS0000055593.V332895.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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