Inspection on 21/11/06 for Coppice House

This inspection was carried out on 21st November 2006.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coppice House 10/05/07

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 21st November 2006 09:30 Coppice House DS0000055593.V313672.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.V313672.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.V313672.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 To be appointed Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 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 five 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 £1549.00 to £1870.78 per week. Coppice House DS0000055593.V313672.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 November 2006 and included two visits to the home on the 21st and 23rd November. Since the last inspection a new manager has been appointed and he was present throughout the visits. Time was spent observing people living at the home and chatting to four members of staff about the care provided. One person completed a comment card with the support of staff. Feedback was received from healthcare professionals working with people living at the home. The care for three people was case tracked, this involved reading their care plans, medication profiles and examining financial records. Their care was observed and staff were spoken to about the support they provide. A range of records were examined including care plans and personal information, staff files, quality assurance and health and safety records. Regulation 26 reports and the quality assurance audit of the home for 2006 were also taken into consideration. What the service does well: What has improved since the last inspection? Person centred planning is being gradually introduced with key workers involving people living at the home in identifying their wishes and aspirations. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 6 Staff are supporting people to be independent with their personal care and lifeskills. People who had previously been supported by staff to eat their meals were observed feeding themselves. Staff respect the diversity of people living at the home enabling them to make choices about their lifestyles and recognising their different wishes and desires. Robust systems are in place to monitor financial records safeguarding people from possible abuse. Staffing levels are being maintained and staff morale is improving. 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 House DS0000055593.V313672.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.V313672.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The wishes and aspirations of people wishing to move into the home are fully assessed but the home is not always able to meet them. By reviewing the admissions process future admissions will be confident that their needs can be met by the home. EVIDENCE: There are presently two vacancies at Coppice House. No new people have moved into the home since the last key inspection. Concerns have been expressed in the past about the way in which people have been admitted to the home without a thorough consideration of whether the home is fully able to meet their needs. Comprehensive assessments have been completed and information obtained from placing authorities however despite this several placements have broken down. Management and staff are expressing concerns about the last admission to the home and whether their needs can be met in this environment. Records of incidents, use of high-risk physical interventions and a high staff turnover corroborate this. A three-month review was held with the placing authority and family to discuss how they had settled into the home and a further review is planned. The organisation have been monitoring this person closely and sending monthly reports to the Commission and other people involved in their care. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 9 The manager is keen to ensure that this person is given every opportunity to settle into the home and feels that their needs and wishes may not have initially been fully supported. By making sure that they have access to the resources to meet their needs an informed decision will then be made about whether the home can continue to meet their needs. The manager is fully aware of the need for careful consideration of new admissions to the home in relation to safeguarding the wellbeing of others already residing there. He has said that he will review policies and procedures within the home. He is re-assessing the needs of people living at the home and is considering enabling one person to move across to the bungalow. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 10 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): 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The introduction of person centred planning will ensure that people living at the home are consulted about their wishes and aspirations which will be reflected in their individual plans. Improvements in the way in which people are supported and consulted about their lifestyles will empower people living at the home. Further improvements to care guidance will provide staff with the information they need to support people effectively. EVIDENCE: The organisation and staff have received training in Person Centred Planning. The manager has asked three members of staff to work alongside people to develop the first plans in the home. He also envisages using Pathways assessments to complement these plans. People are having regular reviews with input from their placing authorities who supply a community care assessment. Each person has support guidelines in Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 11 place that are developed from these assessments. Three people were case tracked and their plans had been reviewed within the past six months. The diary confirmed that two people are due for annual reviews with their placing authority in the next month. There was evidence that occasionally changes are being made to the support guidelines but there was no evidence of how these are monitored on a regular basis. Each guideline has a section for staff comments but these were not being used. The Person Centred Plans will eventually replace these guidelines. One guideline refers to additional guidelines that were added as a result of an incident. This is good practice. Staff spoken with appeared to have a good understanding of the needs of the people they support. One member of staff was observed interacting positively with a person who likes to sit on the floor. They were sitting side by side and she mirrored the person’s responses in line with their support guidelines. Another person has a communication board and this was used in the morning of the visit to give them information about their activities for the day again in line with their support guidelines. Efforts have been made to promote total communication within the home. The manager plans to replace some communication boards around the house. One person is responsible for adjusting the staff board each day with the photographs of who is on duty. Some staff were observed using a key fob with small pictures of key words used by people. One person explained how they use these in practice. Other staff were observed using makaton sign language. Staff said that in the absence of training they had downloaded information that they could use in the home and are coaching each other in makaton sign language. The home works closely with a Speech and Language Therapist who the manager confirmed would be providing training to staff. An activity coordinator is being appointed who will have a lead on developing total communication further within the home. There was evidence that a house meeting was held in August and minutes were produced in a format using text and symbol. People living at the home have been involved in a quality assurance review of the home. The views of five people who responded underpin this process. People do not have individual advocates but should they need support with a specific issue the manager said that the services of an advocate would be obtained. He felt that parents, relatives, staff and the local Community Learning Disability Team advocate on behalf of people living at the home. Risk management plans are in place that are developed by the organisation’s psychologist and the home manager. These do not cover all hazards encountered by people living at the home. In addition to these there are other risk assessments that cover a wider range of areas. These documents have Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 12 not been reviewed since 2004 or 2005. The deputy manager stated that they are in the process of archiving old information ensuring that staff have access to essential information in the daily files. Risk management plans for one person provide guidelines about how staff should support them to minimise challenging behaviour. Part of these guidelines refer to the person requesting hugs, kissing and stroking and provide responsive interventions which indicate that staff can respond by allowing the hug or kiss unless they object. Such a response by staff sends mixed messages to the person and other people living at the home. This plan needs to be reviewed in an inter disciplinary forum and alternative strategies found which promote positive professional boundaries between staff and people living at the home. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 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 the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are being supported to access activities appropriate to their needs and interests, promoting their quality of life. People are assisted to maintain and develop contact with important people in their lives. Peoples’ individuality is respected and there is an awareness of issues around rights and freedoms. Freshly cooked meals are produced which use fresh ingredients and provide a nutritional diet. EVIDENCE: People living at the home have individual activity schedules which staff confirmed are used as a guide. There was evidence in daily diaries that when people are offered activities for the day they may occasionally refuse. The manager confirmed that activity schedules are being reviewed. Activity Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 14 feedback forms are being kept for any activities carried out. People have access to college courses, horse riding, regular shopping trips to Gloucester and day trips to towns in the area. During the visits people went swimming, to college and to the local garage. People were observed spending time in the gardens and being supported in the lounge. Some people chose to spend time in their rooms and were monitored by staff, as indicated in their support guidelines. A range of activites are provided at home including massage and pottery. People were observed using personal CD players and playing games. A sensory room is being developed which one person was observed using during the visits. People also have access to computers in another room. Staff feel that at times the levels impact on their ability to support people to access activities. Rotas confirmed that over the past two months staffing levels have been maintained at the agreed minumum of 6 people per shift, including the team leader. The manager is reviewing the support provided to people and shift patterns. One person has their own vehicle which staff confirmed is for their sole use. There are two other vehicles, one of which is unreliable needing regular maintenance. A problem in the past has occurred due to lack of drivers but the manager hopes that this situation will be resolved with the appointment of new staff. People are supported to maintain contact with family and friends. The manager said that attempts have been made to establish email contact between one person and their family. Others keep in contact over the telephone and through visits. Contact is recorded in the daily diaries. People were observed deciding where to spend their time and with whom. Times for getting up and going to bed are flexible. During the first visit one person had decided to stay in bed a little later than usual. The manager is considering how to support one person, who is unable to use a key, to have a suitable locking device for their room to ensure their privacy. Where there are restrictions to freedom these are accounted for in their support guidelines. A full time cook is employed to prepare a main meal at lunch time. Menus indicate that a range of meals are provided using fresh and frozen vegetables. The diversity of people living at the home is reflected in the meals provided. On the day of the visit people were observed enjoying a breakfast of cereal and fresh fruit, cannelloni and fresh vegetables for lunch and tuna mornay for tea. In between meals people had access to fresh fruit and drinks. Staff were observed offering people a choice of drink or snack. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 15 The manager stated that staff have purchased specialist equipment, including bowls and plate guards to enable people to eat their meals independently. A person was observed using a specialist bowl at mealtimes. Since the last inspection a nutritionist has given advice to the home about the dietary needs of one person who has a diet which includes full fat milk and regular snacks to maintain their weight. Their weight is being monitored. The manager stated that he has plans to refurbish the kitchen in the bungalow to offer the opportunity to people living there to prepare their own snacks and meals. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 16 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): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The way in which the people living at the home would like to be supported is clearly recorded and managed ensuring that their personal care needs are being met. People living at the home have access to a range of healthcare professionals making it possible to meet their physical and emotional health needs although recording systems could be improved. Systems for the administration and control of medication are getting better ensuring that people living at the home are not put at risk. EVIDENCE: Support guidelines indicate the way in which people would like to be supported. Staff spoken with have a good understanding of the needs of the people being casetracked. The home works closely with the local Community Learning Disability Team including the speech and language therapist. Members of the team confirmed they have regular input at the home although in the past their recommendations are not always being implemented. The manager has said that he plans to request the team to provide training to staff Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 17 at the home. He anticipates that in the future recommendations from the team will be actioned. Although it was possible to verify that healthcare appointments are being made with doctors and an optician it was not possible to check whether appointments are made with dentists. The manager stated that appointments are made for some people with local dentists and that there are plans to make appointments for others with a visiting dentist. Chiropody appointments are also arranged at home. The manager said that health action plans are going to be introduced and these will provide a record of all healthcare appointments. Medication administration systems were examined and found to be satisfactory. Protocols are in place for the use of ‘as necessary’ medication and the manager confirmed that a protocol is being drawn up by the Community Learning Disability Team for a new ‘as necessary’ medication. Liquids and creams are labelled with the date of opening and the manager monitors stock levels of all medication. A best interests meeting is being set up with the Community Learning Disability Team to discuss the covert administration of medication to one person. The manager also sought advice from the Commission’s pharmacist inspector. The manager is reviewing medication policies and procedures. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints are handled objectively and any concerns are acted on. Improvements in the recording systems would provide evidence that an open and positive atmosphere is being promoted. There are vulnerable adults procedures in place and staff training is given in their use, providing staff with the knowledge and awareness to recognise and report incidences of abuse. Providing clear and specific information to staff about the interventions they may need to make would safeguard people from possible harm. Improvements in the systems for the administration and control of personal finances safeguard people from possible abuse. EVIDENCE: The organisation has a complaints policy and procedure that the manager intends to review as part of his overall review of procedures within the home. People within the home who are unable to express their views verbally do not have access to an advocate although they have regular contact with other healthcare professionals and relatives. Concerns were expressed to management since the last inspection by staff about the practice of colleagues and these were dealt with appropriately. The Commission was kept informed throughout and the Adult Protection Unit was involved. As a result of these investigations staff have been disciplined and further re-training has been arranged. The manager stated that no complaints have been received Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 19 although several concerns had been received and actioned. It is recommended that any concerns received be logged in the complaints file. An annual quality audit of the home indicated that people would complain to their key worker or the manager if they had concerns. A comment card returned to the Commission also confirmed this. Staff indicated that there is heightened anxiety within the home due to the nature and number of incidents they are dealing with from one person who poses significant challenges to the team. There are support guidelines in place that indicate possible triggers and responses. One guideline suggested staff use ‘breakaway techniques’. This appears a little vague and staff indicated that they need specific guidance on how they should respond in line with the training they receive. Best practice would indicate that these guidelines and protocols should be put in place by an inter disciplinary forum. There was evidence that the team and management are reflecting upon how to safeguard other people when an incident occurs which may involve incident bystanders. Additional training was taking place during the visits to complement Management of Response to Emotion (M.O.R.E.) training that all staff receive. Staff took part in a session designed to specifically address issues faced at the home where in the past they have resulted in using ‘supine’ restraint. Alternative approaches were explored and staff and management reported to feeling more confident in the use of these. This is good practice. Comprehensive records are being kept for all incidents including the use of physical intervention. The Commission receives Regulation 37 notifications about any incidents affecting the wellbeing of people living at the home. Concerns were highlighted at the previous inspection about the monitoring and administration of personal finances. A team leader explained the processes in place to minimise errors and to monitor expenditure. Balances are checked at each handover. Receipts are obtained for purchases and cross-referenced to the finance record. People have access to savings accounts. Financial records examined for the three people being case tracked were satisfactory. Staff confirmed that they have training in the safeguarding of vulnerable adults as part of their Learning Disability Award Framework training and the manager said that some staff are scheduled to attend the ‘alerter’s guide’ training with the local adult protection team. Discussions with staff confirmed their understanding and awareness of abuse. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 20 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, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Coppice House provides spacious accommodation that is clean and tidy. There is an ongoing maintenance and refurbishment programme in place making sure that the home continues to meet the needs of the people living there. EVIDENCE: Coppice House provides large spacious communal areas including new sensory and computer rooms providing additional quiet areas off the main lounge. People were observed enjoying using the extensive grounds. The manager has plans to develop the grounds to provide safe areas that the people living at the home can enjoy. This will include creating an activities room out of a large shed and removing animal enclosures that are no longer used. The manager has identified areas within the house and bungalow for refurbishment including replacing flooring in the kitchen and downstairs toilet. He also intends to alter the first floor bathroom into a separate shower and separate bathroom. The shower in the ground floor toilet that is not used will then be removed. A privacy light is going to be fixed to the toilet door so that people are aware when this room is in use – people do not always choose to lock the door. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 21 Two bedrooms have door alarms to safeguard people at risk from seizure. Staff were observed monitoring one person who had gone to their room. They had been alerted when the door alarm sounded and then monitored every fifteen minutes to ensure they were safe. Protocols and risk assessments for their use are in place. These alarms appeared to be very intrusive. The manager said that they would be monitored. A housekeeping position has been advertised but until a housekeeper is appointed staff have responsibility for cleaning the home. At the time of the inspection the communal areas of the home were clean and tidy. New sofas and chairs have been ordered for the lounge and the light fittings that are broken are due to be removed. The manager described how communal areas would be redecorated to give the rooms more definition. The bungalow is pleasantly decorated and there are plans to refurbish the kitchen so that people can use the facilities to make snacks and meals. These are presently being provided from the main house. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 22 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): 32,33,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A period of stability within the staff group will improve morale within the teams and provide greater consistency and continuity of care to the people living at the home. The standard of vetting and recruitment practices has improved slightly but service users are still potentially at risk due to staffing levels and staff working without Criminal Records Bureau checks in place. Proposed training for staff will provide a staff team who have the necessary skills and knowledge to support people living at the home. EVIDENCE: Staff confirmed that after their induction they attend Learning Disability Award Framework training and would then expect to register for their NVQ Awards in Care. Induction programmes for two people were partially completed. Two members of staff have a NVQ Award and seven people are registered for their awards. The manager said that a local provider would be giving the staff support with their awards. One member of staff is presently an assessor. Discussions with staff confirmed their understanding and awareness of the needs of the people they support. Staff on duty appeared to be accessible and Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 23 to be able to communicate with people living at the home. Some staff were observed using makaton sign language. Concerns have previously been expressed about maintaining appropriate staffing levels at the home. The manager was appointed on 1st September and said that there are at least six staff scheduled to be on shift and sometimes more, according to the needs of people living at the home. He stated that on one-occasion levels fell to five until he and the deputy manager were able to cover the shift. Rotas confirmed this. The manager has plans to review the rota and the way in which duties are presently delegated within the home. The manager is looking forward to having a complete staff team that will provide consistency and continuity of care. Staff indicated that morale is improving. A staff meeting has been held since the manager has been in post and he has held team leader meetings. He is planning to arrange regular staff meetings. Staff had mixed feelings about communication within the home. Some people indicated that the handovers and communication book were sufficient whilst others felt communication could be improved. Files for four new members of staff were examined. Criminal Records Bureau checks were not available for inspection. These are kept at the organisation’s local office and arrangements must be made for them to be available at the next inspection. There was evidence that each person had a povafirst check in place and that a Criminal Records Bureau check was obtained. People are presently starting work upon receipt of two references and a povafirst check. This is with agreement from the Commission until the home is fully staffed. A risk assessment was in place for one person and the manager stated that they are not allowed to work unsupervised until their Criminal Records Bureau check is obtained. The manager must ensure that he obtains a full employment history including dates of when they worked for previous employers. One person had not provided a full employment history. Although another person had provided a Curriculum Vitae to back up their application form neither contained a chronological record of employment. Files did not contain evidence of identification or current photographs. A training matrix for September was available for inspection confirming that staff training is monitored. Staff confirmed access to mandatory training as well as training in M.O.R.E., autism and epilepsy. The manager stated that training in the communication needs of people living at the home is being set up with the speech therapist responsible for helping the home establish communication profiles. Makaton training is also being arranged. Copies of certificates are kept on staff files. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 24 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): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has a clear developmental plan for the home that promotes the rights and best interests of people living there. The home’s quality assurance programme involves people living at the home in the review of services being provided. Systems are in place enabling the home to provide an environment that promotes the welfare and safety of people living there. Closer monitoring will ensure that these are being completed. EVIDENCE: Since the last inspection a new manager has been appointed who has substantial experience in supporting people with a learning disability and autism. He has the Registered Managers Award and NVQ Level 3 in Care. His application to become registered manager is being processed by the Commission. He has also completed a professional development programme Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 25 with his previous employers. Discussions with the manager confirmed that he has short and long term developmental plans in place to ensure that standards within the home are improved and that outstanding requirements are met. Since the last inspection additional recording systems have been put in place to provide a clear record of which staff have worked each shift. The manager was concerned that there are a number of records within the home that appear to duplicate each other. He said that he and the deputy manager would be developing new systems that would simplify records within the home. Each month the quality assurance manager makes an unannounced visit to the home. An annual audit has also been completed involving people living at the home, their carers, staff and other people involved in their care. Copies of these reports have been sent to the Commission. The manager stated that he would be producing a Business Improvement Plan that would comment on the annual quality audit and identify actions to be taken as a result of this audit. Health and safety records are in place for which staff have responsibility for checking. The following records are completed regularly: • • • Fridge and freezer records Cooked food temperatures Hot water outlets It was noted that fire records indicated that tests had not been carried out in October. The last fire drill was August. The manager plans to supplement annual fire training with six monthly internal training. The fire risk assessment for the home must be reviewed and amended to indicate how often systems are checked and how often drills and training are provided. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 26 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 X 2 3 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 X 3 3 X 3 X X 2 X Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 27 No 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 YA6 Regulation 15 Requirement The registered person shall after consultation with the service user, or representative of his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. (Care plans must demonstrate that people have been consulted about what is important to them and distinguish between the aspirations of the individual and expectations of others. Previous timescales of 31/10/05, 31/03/06 and 31/08/06 not met – work is in progress to introduce Person Centred Planning.) The registered person shall encourage and assist staff to maintain good personal and professional relationships with service users. The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or DS0000055593.V313672.R01.S.doc Timescale for action 31/03/07 2. YA9 12(5) 31/12/06 3. YA23 13(6) 31/03/07 Coppice House Version 5.2 Page 28 4. YA23 5. YA27 6. YA34 7. YA35 abuse. (In relation to providing guidelines that specifically indicate what physical interventions staff are expected to use.) 13(6) The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. (In regard to service users who are adversely affected following an incident of violence or aggression by others must be offered additional support. This may mean involving people outside of the home who can advocate on their behalf. Previous timescale of 31/07/06 not met.) 12(4)(a) The registered person shall make suitable arrangements to ensure that the care home is conducted (a) in a manner which respects the privacy and dignity of service users. (This is with regard to protecting the service users who use the toilet on the ground floor. Previous timescale of 31/07/06 not met.) 19(1)(b) The registered person shall not employ a person to work at the care home unless – (b) subject to paragraphs (6)(8) and (9) he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. (In relation to obtaining a full employment history and providing evidence of a current Criminal Records Bureau check, proof of identity and a photograph.) 18(1)(c)(i) The registered person shall ensure that persons employed to work at the care home receive – DS0000055593.V313672.R01.S.doc 31/12/06 31/12/06 31/12/06 31/03/07 Coppice House Version 5.2 Page 29 8. YA42 13(4) (i) training appropriate to the work they perform including structured induction training. (In relation to the communication needs of service users. Previous timescales of 31/12/05,01/03/06 and 30/09/06 not met, some progress being made) The registered person shall ensure that – (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (In relation to putting in place a fire risk assessment for the home, and completing regular fire tests. Previous timescale of 31/07/06 not met) 31/12/07 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 YA3 YA6 Good Practice Recommendations The admissions policy and procedure should be reviewed. Support guidelines should be monitored. Person centred planning with the use of Total Communication strategies should be used for all service users with communication needs 3. 4. 5. 6. 7. YA9 YA18 YA22 YA23 YA24 Risk assessments should be reviewed. Records of healthcare appointments should be recorded. Health action plans should be put in place. Any concerns received by the home should be logged. An inter disciplinary forum should establish physical intervention guidelines and protocols. Monitor the use of door alarms on service users’ bedrooms. Coppice House DS0000055593.V313672.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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