Inspection on 03/10/06 for Coppice Lea

This inspection was carried out on 3rd October 2006.

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 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 13/03/08

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 Coppice Lea 151 Bletchingley Road Merstham Surrey RH1 3QN Lead Inspector Lesley Garrett Key Unannounced Inspection 3rd October 2006 09:30 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.V314241.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.V314241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coppice Lea Address Coppice Lea 151 Bletchingley Road Merstham Surrey RH1 3QN 01737 645117 01737 642767 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) Coppice Lea (Merstham) Limited Mrs Norah Davey Care Home 44 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (44), of places Physical disability (5), Physical disability over 65 years of age (15), Sensory Impairment over 65 years of age (10) Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 29 beds are for provision of nursing care only. 15 beds are for provision of personal care only. Service users accommodated within category PD - Physical Disability must be within the age range of 55 - 64 years. Date of last inspection Brief Description of the Service: Coppice Lea is a care home for older people with 44 beds, of which 29 are for nursing care and 15 are for personal care. 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 are single with the exception of one double room. 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. It is convenient for the M25 and both Reigate and Redhill towns. The range of fees for the rooms are from £735 - £835. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was held over six hours and commenced at 0930 and ending at 1530. Lesley Garrett lead inspector for the service carried out the site visit and the registered manager represented the establishment and was joined during the morning by the general manager for the company. This was the first site visit since Caring Homes bought the establishment in November 2005 The inspector carried out a tour of the premises and spoke with some service users and staff. Some policies and procedures, care plans and employment records for staff were sampled. The inspector would like to thank the service users, staff and manager of the home for their hospitality during this site visit. What the service does well: What has improved since the last inspection? Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 6 This is the first site visit since the home was bought by Caring Homes but the manager told the inspector that all requirements made during the inspection of August 2005 have now been actioned. 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 Lea DS0000065885.V314241.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.V314241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users that move into the home have their needs assessed by someone competent to do so and are then assured that their needs would be met. The home has no intermediate care beds. EVIDENCE: The manager told the inspector that all admissions to the home have a preadmission assessment. Either herself or another suitably qualified registered nurse would carry these out. Evidence of these assessments was seen in the individual folders and care plans are then generated from the assessment. The home does not provide intermediate care beds. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 9 Coppice Lea DS0000065885.V314241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual plans of care are comprehensive and demonstrate that their health and personal care needs are met. The home has policies and procedures in place for the safe handling of medications and no issues around privacy and dignity were raised. EVIDENCE: The inspector sampled some service users individual files and these demonstrated that they contained comprehensive care plans and risk assessments. There was evidence that service users and their relatives or representatives had been consulted about their content. The manager stated that the home has good support from their local general practitioner (G.P.) who visits every week and will see all those service users on the list and gives them time to discuss their problems. The manager also said that the G.P. reviews all medications regularly for service users. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 11 The home also has support from other visiting professionals the opticians’ dentist and chiropodist all visit regularly. There is also support from the speech and language specialist, physiotherapist and dietician. The inspector sampled the medication administration chart for some service users and found there to be no gaps on the charts and reasons for nonadministration written on the back. One service user was self-medicating inhalers and a risk assessment was in place for this activity. The registered nurse that the inspector spoke with had a good knowledge of the home’s procedures for medication administration and policies and procedures were in place and seen by the inspector. The inspector witnessed no issues around privacy and dignity. Staff was observed to be knocking on doors prior to entering and the service users preferred name is documented in their individual service user folder. All service users can be seen in private by visiting professionals. Privacy and dignity training is included in the induction for all new staff. Coppice Lea DS0000065885.V314241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements for meeting service users social needs were a good standard and based on individual needs and expectations. Service users were able to exercise choice and control over their lives as much as they are able. Visitors were made welcome by staff. The presentation of food and arrangements for provision of meals was to a good standard. EVIDENCE: The manager told the inspector that the home has an activity organiser that works Monday to Thursday and another one that works on a Friday. The programme that was displayed demonstrated that a range of activities takes place that includes large group and one to one and service users can select what they wish to participate in. The programme is displayed on the notice board and a newsletter is produced every week. Visitors are welcomed into the home with no restrictions placed on them and the inspector observed family and friends coming in and out of the home on the day of inspection. The manager stated that a local church visits every other Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 13 Friday for a church service and this was seen on the activity programme. Local schools have visited the home on special occasions and this year they held a design an Easter card, which was judged, by the service users at the home. The home enables a service user to manage their own finances otherwise no other service user manages their finances it is done by their relatives or representatives. The manager told the inspector that service users could have choice and control over their lives and staff assists them to do this. They choose where to eat their meals, and when to go to bed and get up in the morning. They have choice about what to wear in the morning and the staff enable service users to do this. The inspector met the chef and he told the inspector that he meets all new service users and this gives them the opportunity to tell him their likes and dislikes. He works on a four-week cycle of menus and all contain fresh meat, vegetables and fruit and gives service users a good choice. Some service users that the inspector spoke with were complimentary about the food at the home. Fridge and freezer temperatures are taken regularly and documented and also recorded is the temperature of the food prior to service. The chef told the inspector that the kitchen has a through clean on Wednesdays when all staff are on duty to help. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their complaints will be listened to and taken seriously. Service users are protected from abuse. EVIDENCE: The home has a complaints policy which the inspector sampled this is available to every service user and is also displayed in the reception. A complaints log is kept by the manager to show the nature of the complaint and the investigations that take place and the outcome of the complaint. The manager told the inspector that she has received two complaints this year both of which are now resolved. The inspector sampled the complaints received by the home and they had been investigated and resolved within the stated timescales. Service users at the home are protected from abuse. The manager told the inspector that the home has had one referral under the local authorities safeguarding adult’s procedures this year, which is resolved. The inspector sampled the home’s safeguarding adult’s policy, which was in line with Surrey Multi Agency Procedures. The manager had a good knowledge of the procedures and told the inspector that she has had training on this subject and this is ongoing training for all staff. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 15 Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and well-maintained environment, which is clean with no offensive odours. EVIDENCE: The layout of the home is suitable, accessible and well maintained. The inspector saw several bedrooms and all had been personalised by the service users. There were lounges and a dining room, which had suitable tables and chairs and was attractively laid up for lunch. The home employs a full time maintenance person who is responsible for implementation of the routine maintenance programme. Bedrooms are decorated when vacant and all looked a good standard and communal areas looked well maintained. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 17 There are large grounds to the property which service users have access to in the good weather. These are well maintained and safe and the manager said they are well used by service users and visitors. The home has good laundry facilities and individual items of clothing are put into baskets for delivery to the bedrooms. The laundress has knowledge of infection control and one of the washing machines has the facility to sluice the washing. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skill mix of staff ensuring they are in safe hands at all times. The home has a good recruitment policy and practice to ensure service users are protected. There is regular training available for all grades of staff to ensure they are competent to do their jobs. EVIDENCE: The inspector sampled the home’s duty rota that was with the pre-inspection questionnaire and also on the day of the site visit. It demonstrated that there was adequate staff on duty to meet the needs of the service users. The manager told the inspector that dependency levels of the service users are reviewed at least monthly and staff numbers can be increased if necessary. The manager also stated that they do have staff that work on the bank and are therefore available to work at short notice so this minimises the need for agency staff. The manager told the inspector that over 50 of her care staff has the National Vocational Qualification (NVQ) at level 2. The general manager stated that a company now provides the training so this is always available for the Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 19 staff. All care staff is registered with the skills for care training programme following induction. The inspector sampled some staff recruitment folders and found that the home had good recruitment practices, which protect the service users. The inspector sampled the three members of staff who were the newest recruits and found that one had started that day. Criminal record bureau checks had been made and the member of staff was having induction and working with another member of staff. Two satisfactory references had also been received prior to commencing employment. The other two staff recruitment folders had all the necessary documentation in place prior to commencing their employment with the home. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is managed by an experienced person who discharges her responsibilities fully. There are good quality audits in place and the service users views are sought. Financial interests of service users are safeguarded and their health and safety is promoted and protected. EVIDENCE: The current manager has been in place since December 2005 and she told the inspector that although a few changes needed to be made staff has supported her and service users have been consulted. The manager told the inspector that her Registered Managers Award has been achieved. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 21 The manager told the inspector that regular quality audits take place and these also seek the views of the service users. The results of these surveys are fed back at the resident meetings and in a newsletter. The manager told the inspector that the latest survey is at head office and she was waiting to hear the results. Other visiting professionals are also sent questionnaires. Policies and procedures are updated every year but the manager said these could also be updated sooner if something had changed. The inspector saw evidence of this during the site visit. The manager stated that service users are able to have money held at the home on their behalf. The administrator manages these accounts and statements are produced each month and relatives or representatives can top the accounts up when funds become low. The money is kept separately and receipts kept. The pre-inspection questionnaire was used to check that all health and safety checks were being made. The inspector also spoke with the maintenance person who explained the system that was in place at the home for checking systems and recording for example the hot water checks and fire alarm checks. These checks are all recorded in his book and are accessible for the inspector to see. Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 22 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 X X X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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.V314241.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coppice Lea DS0000065885.V314241.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!