Inspection on 21/06/05 for Coppice Wood Lodge

This inspection was carried out on 21st June 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 Wood Lodge 05/09/07

Coppice Wood Lodge 24/07/06

Coppice Wood Lodge 21/02/06

Coppice Wood Lodge 20/12/04

Coppice Wood Lodge 01/06/04

Similar services:

Clovelly House Residential Home Ltd

Cherry Orchard Nursing Home

Coppermill Care Centre

Fountains Care Centre (The)

Eleanor Palmer Trust Home

Elmstead House

Bridgeside Lodge Care Centre

Dalemead

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

CARE HOMES FOR OLDER PEOPLE COPPICE WOOD LODGE 10 Grove Road London N11 1LX Lead Inspector Teferi Degeneh Announced 21 June 2005 @ 9:30 am 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 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 WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Coppice Wood Lodge Address 10 Grove Road, London N11 1LX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020- 8366 6565 Mr Steven Tall for London Borough of Enfield Mrs Catherine Gallagher PC Care Home only 44 Category(ies) of DE(E) Dementia over 65 registration, with number of places COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 One specified service user who is under 65 years of age and has alzheimers may be accommodated in the home. The home must advise the regulating authority at such times as the specified service user attains 65 years of age or vacates the home. Date of last inspection 20 December 2004 Brief Description of the Service: Coppice Wood Lodge is a purpose built local authority care home. The home is owned and managed by the London Borough of Enfield and is located within approximately five minutes walking distance from the Arnos Grove Underground on the Piccadilly line. Bus stops and local shops are also within a short walking distance from the home. The home is registered for up to fortyfour older people who may have dementia. However, as part of a plan to make all bedrooms single occupancy, currently the home can accommodate thirty seven people. Only one of the existing bedrooms is being used as double. The home is a two-storey property with a lift to all floors. Coppice Wood Lodge is divided into four units; each with a number of bedrooms linked to a lounge. One unit is on the ground floor and the other 3 are on the first floor. Two care staff are assigned to each of the units during late and early shifts. The night shifts are covered by three waking night staff and a sleeping-in senior member of staff. There are a number of bathrooms, toilets and washing facilities throughout the home. The home is accessible for people with mobility difficulties. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place between the hours of 9:25 am and 5:00 pm on 21st June 2005. The manager Mrs Catherine Gallagher, was present throughout the inspection. A number of people who live at the home were observed and spoken to individually. Two visiting relatives, two volunteers, a health visitor and six care staff were spoken to separately and in groups at different times during the course of the inspection. A relative was kind enough to ring and share their views about the home. Sixty feedback cards and letters were sent by service users, relatives and professionals as part of the inspection. Service users’ and the staff files were assessed. Other records such as the rota, menu, and medication administration record (MAR) sheets and the home’s diary were examined. This inspection is also based on the views gathered during the guided tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: There is a need for the registered person to review the staffing level and ensure that there are adequate number of staff at all times to meet the needs COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 6 of service users. The storage, recording and administration of medication need to be looked at in order to ensure the health and safety of service users. The outcome and the action plan developed as a result of the process of the quality assurance system must be made public. This means that feedback needs to be given to all stakeholders including service users and the Commission for Social Care Inspection (CSCI). The registered person is required to ensure that emergency lights are tested regularly. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 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 standard(s) 3 and 5 Systems for admission to this home are adequate ensuring that admission can take place on the basis of full information about the needs of the service users and the services and facilities of the home. This has enabled service users to be confident that their needs can be met by the home. EVIDENCE: Files of four people who have recently been admitted to the home were examined. It was evident in these files that the home has received a copy of assessments from social workers and reports from health professionals. In a discussion with the inspector the manager confirmed that new service users are also assessed by the home. Two relatives stated in a letter and a feedback card that they visited the home on at least three occasions before a new person was admitted. It was clear from the letters that the new person had an opportunity to visit the home at different times to see the facilities and to meet with the people who live and work at the home. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 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 standard(s) 7, 8, 9 and 10 There is clear care planning system to identify and adequately meet service users’ needs. The health needs of service users are met with evidence of good multi disciplinary working taking place regularly. The system for keeping, recording and administering medication is poor and service users’ are at risk. The staff of this home have satisfactory knowledge and experience, which have ensured service users’ respect, privacy and dignity are acknowledged while receiving care. EVIDENCE: A number of files chosen at a random showed that care plans have been completed for all people living at the home. The registered manager said the staff update care plans two times in a year. As required at the previous inspection, service users have signed to confirm that they have been involved in the review of their care plans. Feedback cards completed by health professionals indicated that service users had regular checks and medical care. From discussions with the manager and the records it was evident that the home has supported the people who live at the home to access health care through the National Health Service (NHS). A visiting district nurse confirmed that she visited the home regularly to assess and provide medical care to some service users. During the inspection a number of service users were observed COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 10 participating in activities, which involved exercising, singing and dancing. The registered manager confirmed that all service users are registered with their own general practitioners. Medication is administered by designated staff members who have completed relevant training. All medicines are kept in a room called “surgery room” situated on the ground floor in front of the office. The records examined showed that on some occasions the temperature in the surgery room was over 25oC. There were discrepancies in the administration of medication. For example, when counting medicines it was found that two people were short of aspirin tablets while two other people had too many of the same tablets in their containers. The six staff spoken to demonstrated a good understanding of ensuring dignity and privacy of people while providing personal care. The registered manager explained that service users are seen by health professionals privately either in the surgery room or in their bedrooms. Thirty-five service users have a single bedroom and screening is provided in the shared room. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 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 standard(s) 12, 13, 14 and 15 Social and leisure needs of service users are met by a variety of activities and facilities available at this home. The staff and management of this home have good attitudes towards visitors. These have enabled relatives and friends to visit service users regularly. The good practices and systems adopted by this home have enabled service users to enjoy meals that meet their needs and to be confident that they can decide on matters affecting their lives within the home. EVIDENCE: A number of people who live at the home were observed participating in singing and dancing co-ordinated by two volunteers who visit the home two times every week. The home has large gardens with furniture where people were seen sitting or walking. A programme of activities has been developed and displayed. Discussions and records indicated that service users had a range of activities including playing games, knitting, reading and going out for lunch. Two visiting relatives said they visited the home regularly and were able to see service users privately in their bedrooms. Feedback cards received from relatives indicated that their visits to the home have been positive. For example, one respondent wrote: “Coppice Wood staff always make an effort to COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 12 welcome you and you feel like you are visiting your relative’s home and not an institution”. Service users’ finances are managed by their families. However, the home receives personal allowances for each service user and pays for personal items and services such as hairdressing and chiropody. It was confirmed that service users’ personal allowances and the home’s petty cash are audited by the Council’s Auditors. There are no restrictions on service users’ movements within the home. It was clear from observations and discussions with service users and the staff that service users are consulted on matters affecting individual or collective needs through care planning meetings or residents meetings. The menu is produced in consultation with the people who live at the home. It is evident from the menu that the home provides a wholesome variety of food that meets the needs of the people who live at the home. The staff were present in the dining room to provide assistance to people who needed help with feeding at lunchtime. A number of the service users spoken to said they were happy with the meals provided at the home. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 13 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 standard(s) 16 and 18 The home has satisfactory complaints procedure with the evidence that service users and relatives feel that their views are listened to and acted upon. The home has satisfactory procedures and knowledgeable staff to ensure that service users are protected from abuse. EVIDENCE: Two visitors spoken to said they are aware of the home’s complaints procedure. They said the manager is approachable and easy to talk to if they had concerns. All the twenty-five relatives who completed the feedback card ticked “Yes” against the question that asked them if they knew about the home’s complaints procedure. It was evident from discussions with the manager and the records that service users’ concerns have been listened to and satisfactory responses made. The complaints procedure is displayed in the corridors for service users and visitors to see. The home has also a policy and procedure on the protection of people from abuse. All the staff spoken to were able to give satisfactory description of what abuse means and what actions to take to protect old people from abuse. Staff files and discussions with the staff and the manager showed that the staff have attended training on the protection of vulnerable people from abuse. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 14 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 standard(s) 19 and 26 The standard of the environment within this home is good providing service users with an attractive, safe and homely place to live in. EVIDENCE: It was evident from the tour of the premises that the home has been well maintained. The registered person has complied with the requirements and recommendations of the officers from fire safety and environmental health service. People who live at the home and their relatives are happy with the facilities of the home. One relative commented that the home was always clean and there was no trace of bad odours. All areas inspected, including a number of bedrooms, were clean and tidy and had no offensive smell. Appropriate facilities are provided to enable service users with a physical disability to access the garden and all parts of the home. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, and 30 The staff at this home have good skills and attitudes to ensure that service users are treated with respect and dignity and their needs are met. Service users are confident that the staff who work at the home are appropriately recruited and are fit to provide care that meets their needs. The staffing arrangement and the staffing level of this home are not satisfactory. These have potentially put service users at risk. EVIDENCE: Two care staff are allocated to work in each of the four units in the home. The number of people in the units varies from nine to eleven. It was also clear from documents, observations and discussions with the staff that the needs of the people in different units varied greatly. For instance, some people would like to go for a walk while others may like to stay in bedroom or in the unit’s lounge. Added to this, care staff have a responsibility to carry out laundry tasks in the laundry room situated on the ground floor, far away from some units. Night shifts are covered by a sleeping-in senior staff and three waking night staff. The staff are experienced, committed and well liked by the people who live at the home and by the relatives. A relative, who had completed a feedback card, rang on the day of the inspection and said: “The staff do miracles. They are most incredible. They saved [a service user’s] life”. Four files of the most recently employed were assessed and showed that written references and satisfactory CRB checks had been obtained before the staff started work. The manager confirmed that all staff have undergone satisfactory CRB checks. The staff said they have all received terms and conditions of employment. The manager and the staff stated that newly employed staff undergo induction training by the Council and by the home. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, and 38 Even though an encouraging progress has been made regarding the implementation of a system of quality assurance, service users are not confident about the process as they have not been made aware of the outcome and action plan proposed to improve the quality of the services. The home’s procedures for monitoring service users’ expenses are satisfactory ensuring that all incoming and outgoing money is accounted for and audited regularly. The premises and facilities of the home are safe for service users with the evidence of regular maintenance and checks being undertaken. However, the health and safety of service users is compromised by emergency lights, which have not been tested on schedule. EVIDENCE: Discussions with visitors and relatives showed that the manager is approachable and open to ideas. Evidence was available to show that service users’ have regular meetings. Questionnaires have been developed and administered to service users, relatives and professionals. A summary of the COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 17 outcome of the questionnaires was seen and the manager said an action plan has been developed but is yet to be made public. As previously stated service users’ finances are managed by their families. Records are kept for all transactions regarding expenses on newspapers, toiletries, hairdressing, private chiropody and holidays. The registered manager has ensured that facilities and equipment at the home are tested and are in good working order. Records were available to indicate that all portable electrical appliances have been tested and fire officers visited the home. Written evidence confirmed that electrical wiring has been inspected in all rooms where maintenance works have been carried out. The lift is serviced once every month and the last time it was serviced was on 6th June 2005. The gas boilers were inspected on 29/11/04. The emergency lights which were due for checking on 1st June 2005, are yet to be inspected. Records and discussions with the staff showed that a number of the staff have attended first aid training. COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 x x 2 COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 19 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 9 Regulation 13(2) Timescale for action The registered person must must 21/7/05 make arrangements for safekeeping of all medicines received into the home. The temperaure of the area where medication is stored must not exceed 25 degree celcius. 21/7/05 The registered person must make arrangements for the recording, handling and safe administration and disposal of medicines received into the care home. The registered person must undertake an investigation into how discripancies in the administration of aspirin tablets and what actions have been taken to prevent similar incidents from happening in the future. A report of the outcome of the investigation and proposed actions must be forwarded to the CSCI inspector. The registered person must, 31/7/05 having regard to the size of the care home, the statement of purpose and the number and needs of service users, ensure that at all times competent and experienced persons are working at the home in such numbers as Version 1.20 Page 20 Requirement 2. 9 13(2) 3. 27 18(1)(a) COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc 4. 33 24(1)(2) 5. 38 23(2)(4) are appropriate for the health and welfare of service users. The registered person must make a copy of the report of the quality assurance available to all stakeholders including the CSCI. The registered person must ensure that the emergency lights are inspected and are in good working order. 31/8/05 21/7/05 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. Refer to Standard Good Practice Recommendations COPPICE WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 WOOD LODGE G59 S30826 Coppice Wood Lodge V221421 21.06.05 Stage 4.doc Version 1.20 Page 22 - 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. 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