Inspection on 01/11/05 for Coppice Nursing Home

This inspection was carried out on 1st November 2005.

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 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 Nursing Home 16/01/07

Coppice Nursing Home 07/06/05

Coppice Nursing Home 13/10/04

Coppice Nursing Home 17/04/04

Coppice Nursing Home 26/11/03

Coppice Nursing Home 24/06/03

Coppice Nursing Home 16/10/02

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

CARE HOMES FOR OLDER PEOPLE Coppice Nursing Home 84 Windsor Road Oldham Lancashire OL8 1RQ Lead Inspector Mrs Fiona Bryan Announced Inspection 1st November 2005 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 Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 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 Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coppice Nursing Home Address 84 Windsor Road Oldham Lancashire OL8 1RQ 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) 0161 626 8522 0161 627 4358 Riseway Care Homes Limited Mrs Kathleen Knox Care Home 44 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (15), Old age, not falling within any other of places category (19), Physical disability (24), Physical disability over 65 years of age (24), Sensory impairment (1) Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No more than 25 service users to be admitted for nursing care. No service user under 55 years to be admitted to the home. The home manager shall be a first level registered nurse and be supernumerary for a minimum of 35 hours a week. Number of persons accommodated - 44. One registered general nurse to be on duty 24 hours a day. Date of last inspection 7th June 2005 Brief Description of the Service: The Coppice is a large detached home set within a walled garden, which has been extended and extensively modernised to provide nursing care and personal care for up to 43 service users. The home is owned by Riseway Care Homes Limited, which is a privately owned company. The Coppice is under the day-to-day control of a general manager who is also a qualified nurse. Accommodation is provided over two floors. Thirty-nine of the rooms are single en-suite whilst two bedrooms and one double room without en-suite facilities are provided with hand washbasins. Two bathrooms and a shower room are provided on the ground floor and a further two bathrooms are provided on the first floor. One dining room is situated on each floor. The first floor has one lounge area whilst the ground floor has one large lounge incorporating a bar area and two further small lounges. The home is located close to the town centre and is accessible to local transport services. There is ample car parking space for those travelling to the home by car. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the second inspection of the year. At the last inspection in June the home was performing satisfactorily in many areas so the purpose of this inspection was to review progress in the small number of areas that were identified as needing improvement. This was mainly related to how the needs of residents were assessed, planned and recorded. Six other key standards, which have to be assessed at least once year were not examined at the last inspection, and were therefore considered at this inspection. These standards included how the home dealt with medicines, staff recruitment, residents’ personal finances and health and safety procedures and practices and also looked at the qualifications of the manager and the care staff. Standards which were not assessed at this inspection, were considered to be satisfactory at the last inspection. For further information about how the home met these standards please refer to the report of the inspection on 7th June 2005. Time was spent talking with residents and staff. A selection of documents was examined including residents’ care files, medicine administration records, staff personnel files and maintenance records. Prior to this inspection comments cards were sent to GP’s who visit residents in the home. Two responded positively stating that staff had a clear understanding of the care needs of residents. Comments cards for residents and visitors were distributed and twelve residents and six relatives had responded at the time of writing this report. Information was also gathered from a questionnaire that the manager completed before the inspection. What the service does well: One relative wrote in a comments card “My mother is full of praise for the food and services provided in the care home and for the caring nature of the staff involved”. Another relative commented “My father is very well cared for. He is always very clean and well fed. I find the management very approachable and willing to help with any concerns I have. Excellent care”. One resident stated in a comments card “The staff are very caring”. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 6 A resident who was quite new to the home was pleased that he had been able to bring some items of furniture in to the home with him and was very happy with his room saying “you can’t fault the accommodation”. A relative said “the change in my mother …… is unbelievable. She now has the love and care of good staff who make sure she even has her makeup on. She will talk to anyone and they encourage her to do this. Her appearance has changed for the better. I’m happier because she is now”. 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. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 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 Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 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 Residents are assessed before coming into the home. EVIDENCE: Three residents’ care files were looked at in detail. All three contained copies of the care management plan from social services. In all cases staff at the home had also undertaken their own assessment and this information had been used to identify residents’ care needs and develop care plans. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 9 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 and 9 Residents’ needs are set out in individual care plans but more rigour is needed to ensure that the information provided is clear, accurate and complete. Some of the home’s procedures for dealing with medicines put the residents at risk. EVIDENCE: Three residents’ care files were looked at in detail. Care plans had been developed from the information gained during the assessment process. However, on occasion information was confusing or contradictory, for example the nutritional risk assessment for one resident indicated that they should be weighed weekly but the care plan stated that they should be weighed monthly. Greater attention to detail is also needed to ensure that all relevant information is included in the care plans as in two cases although the residents were being nursed on pressure relieving mattresses, this was not recorded in their care plans. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 10 The care plan for one resident was not being carried out in accordance with the actions stated, as the resident was not able to cooperate with being weighed (the care plan stated that the resident should be weighed monthly). Care plans should reflect the care that is given in practice, therefore this care plan should be amended and other measures implemented to assess the resident’s nutritional state. Wound care plans remained detailed and thorough. Records showed that residents had been seen by GP’s, chiropodists, opticians and the tissue viability nurse. One of the nurses has been designated as the home’s link nurse for tissue viability, and as such has received training in the treatment of leg ulcers and the application of compression bandaging. Medication administration details were handwritten. These transcribed details had not been signed, dated or validated by an additional member of staff. Examination of a selection of residents’ medicine administration records revealed some discrepancies between what was written on the record and what was stated on the prescription, for example one handwritten record indicated that a resident was receiving 100milligrams of Levothyroxine, the record had been incorrectly transcribed as the resident was in fact prescribed 100 micrograms. The resident had however received the correct dose. On examination of the medication storage area a large amount of excess stock was found for one resident. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 11 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): None of the standards in this section were assessed at this inspection. EVIDENCE: Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 12 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): None of the standards in this section were assessed at this inspection. EVIDENCE: Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 13 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 and 26 The home is well maintained and safe for residents to use. The home is clean and pleasant to live in. EVIDENCE: Since the last inspection the carpet in the large lounge on the ground floor has been renewed. Several bedrooms have been refurbished and further bedrooms are scheduled for upgrading in the near future. The home was very clean, tidy and welcoming with appropriate fittings and fixtures, which gave an overall homely and comfortable appearance. Residents were very satisfied with the standards of hygiene in the home. One health care professional who visits the home returned a comments card stating that he felt the entrance to the car park was too narrow, making access potentially difficult especially for larger vehicles, for example ambulances. The registered provider should consider widening the entranceway, in the light of these comments. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 14 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): 28 and 29. Many of the permanent care staff hold relevant qualifications but the use of agency staff on a regular basis reduces the overall ratio of staff who are suitably qualified. Recruitment policies and procedures protect residents. EVIDENCE: The home has accreditation to enable it to provide adaptation courses for qualified nurses from overseas. The majority of the home’s permanent care staff hold a National Vocational Qualification in care or an equivalent qualification. However as there are several care staff vacancies at present and agency staff have been used to cover a significant number of shifts, the inspector could not evidence that the overall target ratio of 50 of care staff to have achieved NVQ level 2 or above had been met, as the qualifications of agency staff must be included and it was not possible to verify what percentage of these staff had achieved the qualification. The manager reported that more care staff are now applying for employment who already hold NVQ certificates and so was hopeful that permanent staff would be recruited in the near future with the relevant qualifications to meet the ratio. Three staff personnel files were examined. All contained completed application forms, terms and conditions of employment, references and appropriate police checks. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 15 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, 35 and 38 The manager has the skills, experience and knowledge to run the home. The systems for the safekeeping of residents’ monies and valuables within the home are satisfactory but changes must be made to the arrangements for how larger sums of money are dealt with. The health and safety of residents and staff was safeguarded by the policies and procedures in place. EVIDENCE: The manager has been in post for ten years and has previously had many years of experience in a variety of settings. She has undertaken the NEBS management foundation course and achieved 60 CAT points towards a management diploma. She also has a Further Adult Education teaching certificate and successfully completed the D32/D33 Assessors course to enable her to provide in-house training for the NVQ candidates. The manager Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 16 regularly attends training sessions and courses to remain updated with current best practice. The majority of service users are assisted with their finances by their families, who will often provide a cash “float” for sundry expenses the residents incur such as hairdressing and newspaper bills. Separate ledger sheets are maintained for each service user detailing any transactions and a balance of any money kept at the home and receipts are kept for all transactions. The home is responsible for the administration of a small number of residents’ personal allowances in cases where no-one else is designated to assist them. The total weekly income from pensions and benefits for these residents is paid into a bank account and the personal allowance after the deduction of the homes fees, accredited to each resident. Written records are kept of these transactions. However, the bank account which residents’ monies are paid into is the company’s business account. Furthermore there are no details available as to how the interest on the residents’ monies is administered. The maintenance person is responsible for checks of the environment and equipment relating to health and safety, for example ensuring that fire exits are free from obstruction and the fire alarms are in good working order. A record is made of these checks. Maintenance records confirmed that utilities such as gas and electricity had been serviced. Staff were observed to be using safe working practices. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 17 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X X 3 Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 18 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 OP9 Regulation 13, 17 Requirement Timescale for action 15/12/05 2 OP9 13 3 OP35 20 The registered person must ensure that handwritten medication details on the medicines administration records are signed and dated, and the details are validated by an additional member of staff. The registered person must 15/12/05 ensure that stocks of medicines are rotated regularly and that stock is checked each month prior to medicine ordering to prevent the build up and wastage of excess medicines and supplies. The registered person must 31/01/06 ensure that residents’ personal allowance is not paid into the company’s business account and must make arrangements to ensure that residents receive any interest accruing on their money. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 19 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. 3 Refer to Standard OP7 OP28 Good Practice Recommendations The registered person should ensure that care plans are detailed and provide specific information to enable staff to effectively monitor and evaluate care delivered. The registered person should continue to recruit permanent care staff with NVQ’s or train existing staff to ensure that the target ratio is achieved. Coppice Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Nursing Home DS0000025431.V263228.R01.S.doc Version 5.0 Page 21 - 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. 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