Inspection on 13/03/08 for Coppice Lea

This inspection was carried out on 13th March 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Coppice Lea 03/10/06

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Coppice Lea 151 Bletchingley Road Merstham Surrey RH1 3QN Lead Inspector Joseph Croft Unannounced Inspection 10:30 13 March 2008 th X10015.doc Version 1.40 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 Lea DS0000065885.V359257.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 Older People. 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 Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coppice Lea Address 151 Bletchingley Road Merstham Surrey RH1 3QN 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) 01737 645117 01737 642767 coppicelea@caringhomes.org Coppice Lea (Merstham) Ltd Mrs Norah Davey Care Home 53 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) Physical disability (PD) The maximum number of service users to be accommodated is 53. 2. Date of last inspection 3rd October 2006 Brief Description of the Service: Coppice Lea is a care home for 53 older people. Provision is for permanent, short stay and respite care. The home is in a substantial Victorian detached property built in the 1880’s. It has been tastefully extended and refurbished, combining unique architectural features and the character of the original building with modern, up to date facilities appropriate to this type of care setting. Bedroom accommodation is on three floors, accessible by passenger lift. All bedrooms have en-suite facilities and all but one are single rooms. There are attractive and comfortable communal areas and pleasant gardens provide opportunities for outdoor recreation in fine weather. Located in a semi-rural location and set in its own five acres of landscaped and wooded grounds. The home is on the outskirts of the attractive villages of Merstham and Bletchingly and is convenient for the M25 and both Reigate and Redhill towns. The weekly fees charged by the home range from £770 to £1200. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 13th March 2008 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the registered manager assisted him throughout. This site visit took place over a period of six hours, commencing at 10:30 and concluding at 16:55. People living at the home prefer to be known as residents, therefore this term of reference is used throughout this report. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the menu, a sample of policies and procedures, records of medication, training records, staff recruitment files and health and safety records. The Inspector had discussions with the manager, one member of the Nursing staff; two support workers, the assistant cook, six residents and one relative who were present at the time of this site visit. Residents informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Residents informed the Inspector that the food was very good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the care home has been used as a source of evidence in this report. At the time of writing this report the Inspector had not received completed surveys from residents or staff. The inspector would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the registered manager and the assistant regional director at the end of this site visit. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 were assessed. 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 use the service are provided with the written information they need to enable them to make a choice about living at the home. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The home has a Statement of Purpose that had been reviewed in January 2008, and a Service Users Guide that was last reviewed in December 2007. These documents include information in regard to the aims and objectives, accommodation, staffing at the home and the complaints procedure. Three care files were sampled as part of the case tracking process. These provided evidence that prospective residents had a pre- admission assessment undertaken prior to admission to the home, which included personal, health Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 9 and social care needs. These assessments were signed and dated. It was noted that one of the assessments had not been fully completed, however, the resident concerned did have a care plan in place. This was discussed with the manager who stated this would be attended to. The manager informed the Inspector that she, or a member of the senior staff team, visits prospective residents at their current placements to undertake an assessment of their needs. The manager informed the Inspector that Health Care Needs Assessments are obtained for funded placements. Visits to the home are encouraged. This was confirmed during discussions with residents, and also a relative of the most recent admission to the home, who informed the Inspector that their relative had an assessment of their needs undertaken before moving into the home. Care plans are developed from the pre-admission assessments. The home follows the organisation’s Admission and Discharge policy and procedure that was last reviewed in July 2006. The manager stated the home does not offer intermediate care. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. 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 use the service have care plans and risk assessments in place that ensure their physical and health care needs are met. Residents are protected by the home’s storage and administration of medication procedures. EVIDENCE: Three care plans were sampled during this inspection. Care plans were appropriately maintained and included information in regard to meeting the personal, physical and health care needs of residents. Care plans had been reviewed on a monthly basis and were signed by residents and/or their representatives. Care plans sampled had annual reviews undertaken. The home uses the key worker system. Staff were knowledgeable in regard to the contents of care plans, and stated that these are reviewed on a monthly basis by the Registered General Nurses (RGN). Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 11 Residents and one visiting relative informed the Inspector that they were aware of the care plan. Care plans sampled contained risk assessments that included falls, nutrition, pressure sores and moving and handling. Evidence was observed that risk assessments had been reviewed regularly and as and when required. Discussion took place with the manager in regard to one risk assessment that did not provide guidance to staff of the action to be taken when one identified resident becomes exposed to the identified risk. The manager informed the Inspector that this would be attended to. From discussions with staff and residents, and from viewing records, it was clear that residents have access to health care professionals as required. These include a General Practitioner, Dentist, Optician and Chiropodist. Staff informed the Inspector that records of monthly weights for residents are maintained. The home follows the organisation’s medication policy and procedure that was last reviewed in December 2006. Medicines are appropriately stored in locked medicine cabinets. Medical Administration Record sheets (MAR) provided by the local pharmacy are used for the recording of administration of medicines. MAR sheets sampled during the site visit were accurately maintained with no omissions identified. The manager and staff informed the Inspector that only the nursing staff administers the medication. The lunchtime medication round was observed, and no issues were identified. The home maintains records of medicines received and returned to the Pharmacist. Controlled Drugs are stored in secure metal cabinets, and a Controlled Drug register that is signed by two members of staff is maintained at the home. During discussions staff informed the Inspector that they respect residents’ privacy and dignity through knocking on bedroom doors, calling residents by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Evidence of these practices was observed during this site visit. This was also confirmed during discussions with residents who stated that staff always treat them in a respectful manner. Information provided in the AQAA informs that the home maintains high standards of health and personal care, and residents’ wishes are taken into account. Throughout the site visit staff were observed to be interacting with residents in a professional manner, and providing support as and when required. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family. Special dietary needs are catered for and meals are varied with individual choices ensuring that residents receive an appealing and balanced diet. EVIDENCE: The home employs an activity co-ordinator who organises activities twice a day from Monday to Friday. Lists of activities are clearly displayed on the notice board at the home. Activities provided include bingo, hand eye co-ordination activities, quiz, exercises, music and boules. During discussions residents informed the Inspector that the activities provided are very good, and that they are able to choose whether or not to join in. Residents receive individual copies of the activity list. The manager informed the Inspector that the home has the use of a mini-bus that is used to transport residents to external activities such as garden centres Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 13 and local attractions, including pubs and theatres. External entertainers also visit the home. Residents and staff informed the Inspector there are no restrictions on visitors to the home. This was confirmed during discussions with one visiting relative during this site visit, although their relative had only recently moved into the home, they stated they could visit the home at any time, and are able to see their relative in private. Residents informed the Inspector that they are able to maintain contact with their families and friends, can make and receive telephone calls in private, and receive their own mail. Staff informed the Inspector that the majority of residents have their own landline telephones in their bedrooms. Residents stated that they make choices every day about their lives, and that they like their bedrooms with the en-suite facilities. All residents living at the home are white British, and hold Christian beliefs. Staff and residents informed the Inspector that a local church leader visits the home every two weeks and provides a religious service. One resident stated that he was an artist and a poet. Examples of his artwork were framed and hung on the wall in one of the lounges. Information provided in the AQAA informs that the home has made more activity hours available during the last twelve months. The home employs a chef and a cook who plan the menus. At the time of the site visit the chef was on a day off, however, the Inspector had a discussion with the cook who stated that she had attended training in regard to food hygiene and handling in 2007, and has attended a course in regard to nutrition for the elderly. The chef is a qualified cook. During discussions the cook informed the Inspector that Menus are discussed with the residents, and they are asked every afternoon which choice of meal they would like the following day. Residents can choose a different meal to that days menu if they wish to, and these are recorded on the individual menu sheets maintained at the home. This was confirmed during discussions with residents. Residents informed the Inspector that the food is usually good, and there is always a choice of meals. Drinks and snacks are always available. The manager informed the Inspector that the chef attends residents meetings to listen to their views and requests. The home uses a four-week menu. These provide a choice of meal and include meat, fish, pasta, a mixture of fresh and frozen vegetables, and fresh fruit. Special diets are catered for, and the kitchen has a list of these and resident’s likes and dislikes. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 14 The home had a visit from the Environmental Health Organisation on the 18th January 2008. No issues were identified. The lunch meal was observed during the site visit. This was seen as a relaxed occasion with sufficient staff to provide support to residents as and when required. Dining room tables were covered with cloths and furnished with flowers. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. 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 use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Residents are protected by staff having training and an understanding of adult protection issues. EVIDENCE: The Commission For Social Care Inspection had received one complaint that was referred to the provider to investigate. The home has a Complaints Policy and Procedure that includes the timescales for responding to the complainant, and the Commission For Social Care Inspection contact details. Information provided in the AQAA informed that the home had received one complaint during the last twelve months. Records of complaints were viewed and provided evidence that complaints received had been resolved within the 28-day timescale. Complainants are sent a letter informing them of the outcome of their complaint. The home also maintains records of compliments received from residents and their relatives, including ‘thank you’ cards. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 16 During discussions residents and one visitor informed the Inspector that they knew how to make a complaint, but have not had the need to do so. From discussions with staff and evidencing the complaints records, it was clear that the home are proactive in regard to responding to, and resolving complaints made. Staff at the home follow the organisation’s Protection of Vulnerable Adults Policy and Procedure that is due to be reviewed in December 2006. This document described the different types of abuse, however, it did not include ‘Professional Abuse.’ This was discussed with the assistant regional director who stated that this would be added to the policy. There is a copy of the recent Surrey Multi-Agency Safeguarding Procedures available in the office for staff to read. Evidence was provided to the Inspector of training that is ongoing for all staff, including ancillary, in regard to Safeguarding Adults. During discussions, staff gave an account of who they would report suspicions of abuse to, and stated they would not hesitate to report bad practice. Staff informed the Inspector they had received training in regard to the Protection of Vulnerable Adults and read the Policies and Procedures in regard to this area. Scenarios in respect of abusive situations were discussed with three members of staff. They were able to demonstrate an understanding of Safeguarding Adults issues and the procedures to be followed. The manager had attended the Surrey Multi – Agency training in regard to Safeguarding Adults in June 2006. The manager had a good understanding of the procedures to be followed in reporting allegations of abuse. The manager must address one identified issue in regard to the recruitment practice of the home that would ensure residents continue to be protected from harm. This has been addressed under the Staffing section of this report. The home has dealt with one Safeguarding issue since 2006. The Commission For Social Care Inspection has not received any Safeguarding issues in regard to the home since the last inspection. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. 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 location and layout of the home is suitable for it’s stated purpose. It is accessible with a pleasant and homely atmosphere; however, identified issues must be addressed to ensure residents continue live in a safe and wellmaintained environment. EVIDENCE: A tour of the premises was undertaken. Since the last inspection the home has added ten new bedrooms that have been registered with the Commission For Social Care Inspection. The home can now cater for the needs of up to 53 residents. All bedrooms have en-suite facilities and all but one are single rooms. There are attractive Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 18 and comfortable communal areas and pleasant gardens provide opportunities for outdoor recreation in fine weather. Bedrooms seen during the site visit were appropriately furnished and residents had their own personal belongings around them including family photographs and televisions. One resident had duvet covers and a light shade in the colours of the football team he supports. Specialist beds and mattresses were provided where required, and bathrooms and toilets were furnished with the appropriate adaptations to enable the needs of residents to be fully met. It was noted in one bedroom that the television was too large for where it had been placed, and could have been knocked to the floor by the resident. The manager immediately took action to rectify this hazard. Other issues that require attention include the décor to the stair way as the wallpaper was coming adrift. On the first floor one identified bedroom had water damage to the wall and ceiling, bathroom number two had a wall mirror with a corner broken off and cracked, and the bathroom was cluttered with walking aids and a trolley. The bed rail in bedroom 25 was noted to require attention. The manager informed the Inspector that this would be attended to immediately. On the second floor, one identified bedroom had paint flaking from the ceiling. A requirement has been made that the registered person must attend to the identified issues in regard to the environment. The lounges in the home were appropriately furnished with ample seating, televisions and tables. During the site visit one activity was observed taking place in one of the lounges. It was noted that the lounge where religious services take place has a religious artefact fixed to a wall that signifies the Christian beliefs of the residents who take part in these services. All communal areas were bright, nicely decorated and the windows were double glazed and fitted with restrictors. The home has a separate hair salon, treatment room, sluice facilities and laundry. Residents had unrestricted access to all communal parts of the home. Communal toilets and bathrooms had been supplied with liquid soap and paper towels. The home employs a team of five domestic staff who also have allocated duties in the laundry. The manager informed the Inspector that domestic staff had attended training in regard to Infection Control. This was verified on the training matrix provided to the Inspector. On the day of the site visit the home was clean, tidy and free from offensive odours. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. 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 arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents. Recruitment procedures must ensure that people who use the service are fully protected. EVIDENCE: The home has a multi-cultural staff team that includes male and female staff. Staffing at the home consists of the registered manager, seven Registered General Nurses (RGN), twenty-five care assistants and catering and domestic staff. The manager informed the Inspector that the duty pattern is a two-shift system, early and late. There are two RGN nurses and seven care assistants on duty during the early shift, two RGN nurses and five care assistants for the late shift, and one RGN nurse and three staff on the waking night duties. There is also one activity organiser, one chef, a cook and a team of five domestic staff. The manager informed the Inspector that she considers the staffing numbers sufficient to meet the needs of the current forty-one residents living at the home. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 20 Residents spoken to informed the Inspector that staff are very good, and available at the home. The home clearly displays a list of who the appointed first aid and fire marshals are for each shift. Information provided in the AQAA, discussions with the manager and the viewing of training records informs that 76 of staff working at the home hold an NVQ level 2 and above. The manager stated that two RGNs are currently undertaking the NVQ assessors’ award training. The home follows the Organisation’s Recruitment Policy and Procedure. Three staff recruitment files were sampled. All but one file contained the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001, including Criminal Record Bureau and the Protection Of Vulnerable Adults (POVA) checks, photographs and proof of identification. However, the manager had only obtained one written reference for one identified member of staff. The manager informed the Inspector on the day following the site visit that the second reference had now been obtained. A requirement has been made that the registered person must not employ a person to work at the care home unless the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended). During discussions staff informed the Inspector that they are receiving the training they require to undertake their roles. Training provided to staff has included dementia awareness, catheter care, pressure sores, fluid intake and oral and foot care. The training matrix provided to the Inspector confirmed that staff are receiving regular training, and new staff attended an induction programme when they commenced working at the home. The manager informed the Inspector that the home has obtained a training programme from E Learning that would enable the home to also provide inhouse mandatory training. Information provided in the AQAA informs that an in-house trainer has increased staff motivation and NVQ training has increased. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 were assessed. 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 arrangements for management and administration ensure the home is run in the best interests of residents, and their safety is promoted and safeguarded. The manager must attend to the identified issues in regard to the recruitment practice and the environment to ensure people who use the service continue to be safe and protected from harm. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has a registered manager who is a Registered General Nurse and has completed the Registered Manager Award (RMA). The manager informed the Inspector that she has fifteen years experience in nursing, and has been managing the home since 2005, and regularly undertakes training in regard to the management of the home. During discussions, staff informed the Inspector that the manager has an open door policy, is approachable and supportive. Staff stated that they receive supervision, which was verified through the records maintained at the home. However, during the site visit the Inspector was not able to evidence that staff were receiving the six supervisions per year as required. The manager telephoned the Inspector the day after the site visit and provided these dates. The manager informed the Inspector that she is to manage another home owned by the organisation, and would be leaving Coppice Lea in April 2008. Staff and residents were aware of this, and all stated that they would miss the manager, as she has been very good and supportive. The organisation has recruited a new manager for the home. Quality assurance is undertaken through monthly meetings with residents, and quarterly meetings are held with residents and their relatives. Minutes of these meetings were viewed during the site visit. Staff meetings are held every two months, minutes of which were evidenced during the site visit. Annual surveys are undertaken to ascertain the views of residents, their relatives and other associated professionals. The organisation conducts monthly Regulation 26 visits, and copies of these reports were available at the home. The manager informed the Inspector that residents and their families are responsible for their finances. The home holds small amounts of money for residents that are kept secure in a safe. Records of monies held were sampled for three residents. The records balanced with the money held in the individual accounts. The sampling of staff training files provided evidence that staff are receiving mandatory training as required. During discussions staff stated that they receive regular training. One member of staff stated that the training opportunities provided by the organisation are very good. Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 23 Staff at the home follow the organisation’s Health and Safety Policies and Procedures that were last reviewed in December 2006. Evidence of staff training in this area was viewed in the training files sampled. Information provided in the AQAA returned to the Commission For Social Care Inspection, informed that health and safety records are appropriately maintained and up to date. During this site visit the following records were evidenced; annual servicing and monthly testing of the fire alarm systems, fire drills, Portable Appliance Testing (PAT), electrical circuits, hoists, fire risk assessments, legionella and the Environmental Health Office report. The manager completed and returned an Annual Quality Assurance Assessment to the Commission For Social Care Inspection. Since the site visit, the Inspector has had discussions to advise the manager to include information in regard to all the key standards for Older People in this document. Coppice Lea DS0000065885.V359257.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP19 Regulation 23 (2) (b) Requirement The registered person must attend to the identified areas in regard to the environment as detailed in the report. This will ensure that residents continue to live in a safe environment. The registered person must not employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended). This will ensure that residents are supported and protected by robust recruitment procedures. Timescale for action 13/05/08 2. OP29 19(1)(b) Schedule2 14/03/08 Coppice Lea DS0000065885.V359257.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. Refer to Standard Good Practice Recommendations Coppice Lea DS0000065885.V359257.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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