CARE HOMES FOR OLDER PEOPLE
Coppice Wood Lodge 10 Grove Road London N11 1LX Lead Inspector
Tony Brennan Key Unannounced Inspection 11:00 5 September 2007
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 Wood Lodge DS0000030826.V351562.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 Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Coppice Wood Lodge Address 10 Grove Road London N11 1LX 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) 020 8366 6565 www.enfield.gov.uk London Borough of Enfield Mrs Catherine Gallagher Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 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 thirtyseven people. 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. Three waking night staff and a sleeping-in senior member of staff covers the night shifts. There are a number of bathrooms, toilets and washing facilities throughout the home. The home is accessible for people with mobility difficulties. The homes most recent inspection is available on the homes notice board and the manager has agreed to put a copy of the homes purpose and function document on display for relatives and service users. The fees for the home are £641.00 per week. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken as part of the annual inspection programme. I sought to confirm that the areas for improvement identified at the last Random inspection were addressed. The inspection took place over one day. Catherine Gallagher, the registered manager, assisted me with the inspection. I received comment cards from people, relatives and professionals about the service provided by the home. I spoke with the five people who live at Coppice Wood Lodge and three members of staff. I observed care practice and interaction between people living at the home and staff. I toured the building and examined a number of records relating to the care, health and safety and management of the home. I would like to thank Catherine Gallagher and all the staff who assisted me by answering questions about the running of the home. I would also like to thank the seven people who live at the home who discussed their views of the service they receive. What the service does well:
The registered manager explained that there is an ongoing review of all services provided by Enfield social services. Currently the home is not admitting people permanently although respite admissions are still taking place. A social worker who had recently placed people on respite commented, “I have had good reports from individuals and their families about the care provided at Coppice Wood.” The registered manager and staff are to be commended for the way they have continued to provide a high standard of care to people. Comment cards received were positive about the information provided to people prior to the admission to the home. The initial assessment of one person case tracked showed that they had made a positive choice to live at Coppice Wood. The statement of purpose stated clearly that the home would respect and promote the diversity of people who live there. A relative commented, “ staff treat the residents kindly, which is all important thing.” Comprehensive initial assessments make sure that peoples’ medical, personal and social needs are identified and met in ways that reflect their personal preferences. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 6 Care plans were personalised, and referred to the cultural needs of people. This included whether or not they wish to take part in religious practices. There were also detailed personal histories that provided information on peoples’ interests and previous occupations. Care plans clearly stated how people wished their needs to be met. A friend of a person living at the home commented that the home had responded appropriately when the person asked to be assisted with personal care by a woman. The friend confirmed that the home had arranged this. Peoples care needs are planned for and met. Diary notes showed that the people case tracked had access to their general practitioner when necessary. A person said, “ I saw the GP in my own room and staff made sure I got the medication he had prescribed.” The records of medicines received, administered and returned to the pharmacist were all complete. People medical needs are met and their health promoted. I observed that activities were taking place at various times throughout the day. In the morning people were engaged in a game of bingo and discussions. In the afternoon there was a sing a long. One person spoken to said, “ I particularly like the musical entertainment.” People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. Diary notes showed that people living at the home had regular contacts with family, friends and the wider community. On the day of inspection people who live at the home went on a trip to Forte Hall. People are supported to be part of the local community. The menu is varied with a number of choices meals are balanced and nutritious. People who live at the home with whom I spoke were generally pleased with the quality of the food provided. A person who lives at the home said, “ the food is very good”. People are able to enjoy the food they prefer and like. Comment cards from people living in the home confirmed that they knew how to make a complaint. People told me that they understood how to make a complaint. A person spoken to told me, “ if youre not happy about something you can talk to the manager or the staff they are very helpful.” People I spoke to said that they were generally extremely satisfied with the service. There were comprehensive policies on handling abuse and protection. A person said, “ I feel safe here.” The home has an open culture where individuals feel safe and protected to share any concerns. I walked round the home and found that it is appropriately decorated and furnished. All bathrooms had been redecorated and refurbished. Corridors had been decorated and new carpets laid. Appropriate measures are in place to prevent cross infection. The environment is maintained to a high standard, which provides people with a safe and comfortable home. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 7 The home has detailed policies on the prevention of cross infection. A person who lives in the home said, “my bedroom is cleaned daily.” The home is always very clean, tidy and smells fresh. I observed that staff were able to effectively meet the needs of people living at home. People living at the home told me that staff are available to meet their needs. A person spoke to said, “ the staff are very good and understanding.” There is consistently enough staff available to meet the needs of people using the service. Staff at the home had undergone training in all the statutory required areas of training. The registered manager explained that at present 50 of staff have achieved the National Vocational Qualification in care. The service puts a high level of importance on training to meet the needs of people. The registered manager has extensive experience of managing a service for older people. The registered manager has maintained and updated her skills regularly and she has a clear understanding of the key principles and focus of the service that works to make sure that people receive the care they need. People and their representatives are consulted about the improvement of the service. The home has an effective system for monitoring accidents to ensure the safety of people who live at the home. Health and safety checks, procedures and training make sure that people living at the home of safe. What has improved since the last inspection?
All areas for improvement identified at the last random inspection were found to have been met. At the last inspection bedroom 19, 20 and 21 had been identified as needing redecoration. The registered manager told me that this work had been done. On my walk round the building I was able to see these bedrooms and confirmed that they had been redecorated. Bedrooms were personalised with items of furniture and pictures belonging to people who live at the home. People living at the home are provided with well decorated and personalise bedrooms that meet their needs. At the last inspection the registered persons were asked to provide the Commission with a schedule for the refurbishment of the bathrooms. This had been received prior to this inspection and detailed how and when the work will be completed. I walked around the home and found that all bathrooms had
Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 8 been redecorated and refurbished. People have access to bathrooms that meet their needs. At the last inspection it was identified that a number of fire doors were wedged open. These included the kitchen and laundry room doors. I walked round the home and found that no fire doors were wedged open. Staff spoken to understood the need to close fire doors. The safety of the people living at the home is maintained by the home’s fire prevention systems and procedures. 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 Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 9 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 Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 10 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): 13 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose is an accurate description of the service provided. People’s needs are assessed prior to admission to the home to ensure they receive the care and support they need. EVIDENCE: Comment cards received were positive about the information provided to people prior to their admission to the home. I spoke with people who live at the home who informed me that they had received information on what the home provided before deciding to come to live at the home. People had also visited the home before they were admitted. The initial assessment of one Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 11 person case tracked showed that they had made a positive choice to live at Coppice Wood. The registered manager explained that there is an ongoing review of all services provided by Enfield social services. Currently the home is not admitting people permanently although respite admissions are still taking place. A social worker who had recently placed people on respite commented, “I have had good reports from individuals and their families about the care provided at Coppice Wood.” I found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The statement of purpose stated clearly that the home would respect and promote the diversity of people who live there. I spoke with a registered manager told me that the home would work positively to support peoples diversity. Comment cards from people and their relatives confirmed that the home is able to meet the diverse needs of people. The statement of purpose also identified the skills and staffing resources that are to be available to meet the needs of people living at home. A relative commented, “ staff treat the residents kindly, which is all important thing.” Three people were case tracked who had come to live at the home since the last key inspection. They had detailed assessments of their needs. Care managers had provided up-to-date and detailed information. Initial assessments identified the needs of the three people. One of the people case tracked told me, “ the care here is generally very good and staff treated me well.” These have been used as a basis for their care plans. The initial assessment of one person case tracked identified the risk of falls. The home had carried out its own risk assessment and put in place a clear plan to prevent the risk. Another person case tracked and specific needs around personal care. The home hand put in place a clear plan that gave staff clear guidance on how to meet this need in a way that reflected the person’s preferences. Staff spoken to were able to describe the needs of these people and how they were met. Comprehensive initial assessments make sure that peoples medical, personal and social needs identified and met in ways that reflect their personal preferences. The initial assessments also provided information on the person’s life history. I read a number of these life histories and found they provided detailed information on the occupation, family background and interests of the people case tracked. People with dementia are supported to maintain their wellbeing. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 12 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): 7 8 9 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal, social and medical care needs are fully planned for. People who use the service are fully protected by safe procedures for handling medication. Peoples right to privacy is supported. EVIDENCE: I found that the care plans of all the people case tracked were detailed and clearly identified how the needs of people would be met. The registered manager explained that care plans had been written in consultation with people and their representatives. In this way it had been possible to ensure that there was detailed information on how they were to be met. The care plan for one person who was case tracked recorded that he liked to choose how and when personal care was provided. The care plan gave guidance to the
Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 13 persons preferences. The person told me, “ staff are very helpful when you need them.” Care plans were personalised and referred to the cultural needs of people. This includes whether or not they wish to take part in religious practices. There were also detailed personal histories that provided information on peoples’ interests and previous occupations. For example, the care plan of one person case tracked identified that she like to spend time reading the newspaper. When I spoke with this person she said, “staff bring me the newspaper to read and know I like to spend time reading.” People I spoke to told me that they felt staff understood the needs. Care plans clearly stated how people wished their needs to be met. A friend commented that the home had responded appropriately when the person asked to be assisted with personal care by a woman. The friend confirmed that the home had arranged this. I observed that staff took time to understand people who live at home and always do things in the way they had been asked. Detailed nutritional, tissue viability, falls and manual handling assessments have been put in place. Nutritional assessments recorded the level of risk and dietary needs of the people case tracked. The weight of people case tracked was monitored regularly. Any changes were noted in their care plan and risk assessment. The registered manager explained that a number of people at the home are at risk of developing pressure sores. They are referred to the district nurses who provide the necessary pressure relieving equipment. I observed that this equipment was in place in the home. A district nurse spoken told me, “the staff identify if pressure relieving equipment is needed. They identify problems before they occur, and always follow up on my advice.” Falls and manual handling assessments identified the risk of falls and the assistance with moving that people required. I observed that staff used appropriate manual handling techniques when supporting people to mobilise. The registered manager told me that people are referred to the occupational therapist so that appropriate professional advice is obtained to promote their continued independence. Training records showed that staff had received training in manual handling. Diary notes showed that the people case tracked had access to their general practitioner when necessary. Diary notes also confirmed that where the general practitioner had recommended specific medical interventions these were followed up and put in place. People spoken to told me they had regular access to their general practitioner. A person said, “ I saw the GP in my own room and staff made sure I got the medication he had prescribed.” Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 14 The records of medicines received, administered and returned to the pharmacist were all complete. Medicines were stored safely. All medicines are stored at the appropriate temperature. No controlled drugs are currently held in the home. The pharmacist commented, “ the medicines are managed very effectively, they are never any problems in this area” The medication policy has recently been reviewed. It has been amended in the light of a report on the safe handling of medicines for people who are staying at the home on respite. I found that the medication for each of the people case tracked was accurately recorded. There were also personalised medication profiles on how individuals responded to taking medication. The general practitioner had been consulted on what each medication does and this had been recorded as part of the person’s medication profile. Changes to medication have been recorded. The general practitioner had signed the changes on the medication administration chart. Medicines held for the people case tracked corresponded with the changes made by the general practitioner. Training has recently been provided on the safe administration of medicines. The home’s pharmacist confirms that he has, “ given training in medicines administration and storage.” I spoke with staff and found they were clear about their responsibilities and how to handle medicines safely. Training records also contained certificates confirming that this training had taken place. I observed staff administering medication and confirm that this was done safely. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 15 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): 11 12 13 14 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are provided with varied activities to meet their needs. People living at the home are supported to maintain contact with relatives and other representatives of their choice. The menu reflects the preferences of people living at the home and offers a balanced diet. EVIDENCE: Comment cards received from people who live at home and their relatives confirmed that activities are provided regularly. I spoke with people who live at the home who told me that they are provided with regular activities. I observed that activities were taking place at various times throughout the day. In the morning people were engaged in a game of bingo and discussions. In the afternoon there was a sing a long. An activities programme is in place. The registered manager explained that one of the people living at the home organises a bingo session on a Thursday. The home is developing a
Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 16 reminiscence programme focused mostly on people with dementia. People spoken to told me that these activities are provided regularly. One person spoken to said, “ I particularly like the musical entertainment.” People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. I observed that staff spend time talking with people who live at the home and listening to what they had to say. Staff spoken to understood the importance of one-to-one contact particularly for people with dementia. One person said, “ staff are very friendly. One of the staff is very helpful and takes time to talk with me about the news.” Peoples’ interests were recorded as part of their care plans and is part of the life history. A relative spoken to told me that there were no restrictions on visiting the home. People who are the home told me that they could see visitors in private if they wish to. Diary notes showed that people living at the home had regular contacts with family, friends and the wider community. On the day of inspection people who live at the home went on a trip to Forte Hall. The registered manager explained that this was part of a regular programme of trips to local places of interest. The menu showed that two options are offered at each meal. The Cook told me the menu is changed seasonally and people who live at the home are asked regularly about the food being provided. The menu is varied with a number of choices meals are balanced and nutritious. People who live at the home with whom I spoke were generally pleased with the quality of the food provided. A person who lives at the home said, “ the food is very good”. Another person commented about the choice of food offered and that staff, “ do bring an alternative if whats on the menu is not to your taste.” There was specific guidance on individual plans where they had dietary needs. I saw that meals were well presented and they were provided in a relaxed manner. People were supported to eat. I observed that this was done at the pace of the people being assisted. Tables were laid out so that people could easily access condiments and individuals were provided with napkins. People are able to enjoy the food they prefer and like. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 17 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): 16 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are confident that their complaints will be listened to, taken seriously and acted upon. The home’s procedures protect people from abuse. EVIDENCE: Comment cards from people living in the home confirmed that they knew how to make a complaint. People told me that they understood how to make a complaint. They also felt that any complaints they raised would be dealt with in a sensitive manner. A person spoken to told me, “ if youre not happy about something you can talk to the manager or the staff they are very helpful.” The complaints policy explained how to make a complaint and how it would be dealt with. I found that copies of the complaints policy were displayed prominently around the home. The complaints record showed actions taken to resolve complaints. There had been no complaints since the last inspection. The registered manager showed me a number of compliments that she had received from relatives. These confirmed along with comment cards and the people who I spoke to that people were generally extremely satisfied with the service.
Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 18 There were comprehensive policies on handling abuse and protection. I found that staff had received training on adult protection matters. People living at the home felt confident that any concerns they raised would be handled sensitively and appropriately. A person said, “ I feel safe here.” Staff spoken to understood the signs that might indicate that a person was being abused. Staff had been on adult protection training. The home has an open culture where individuals feel safe and protected to share any concerns in relation to the protection and safety. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 19 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): 19 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that provides a safe and homely environment. The home is clean and hygienic. EVIDENCE: I walked round the home and found that it is appropriately decorated and furnished. There is a passenger lift providing access for people who live at the home. The home is adapted to meet the needs of people with physical disabilities. They are wide corridors and grab rails to aid people to move about the home safely. Corridors had been decorated and new carpets laid. The
Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 20 colour scheme had been chosen to assist people with dementia to orientate themselves were moving about the home. The relative told me, “ the home is bright and welcoming.” I saw that the bedroom of one person case tracked had been adapted to meet their needs resulted from the physical disability. I spoke to the person who told me that the layout of the bedroom met their needs. All bathrooms had been redecorated and refurbished. The registered manager had a plan of work to be carried out to ensure that the environment in which people lived is homely and safe. Records were available to show the ongoing maintenance of the home is being carried out. The environment is maintained to a high standard, which provides people with a safe and comfortable home. At the last inspection bedroom 19, 20 and 21 had been identified as needing redecoration. The registered manager told me that this work had been done. On my walk round the building I was able to see these bedrooms and confirmed that they had been redecorated. Bedrooms were personalised with items of furniture and pictures belonging to people who live at the home. One person told me, “ I like my bedroom.” People living at the home are provided with well decorated and personalise bedrooms, which meet their needs. Appropriate measures are in place to prevent cross infection. The home has detailed policies on the prevention of cross infection. A person who lives in the home said,” my bedroom is cleaned daily.” Staff have received training on infection control measures. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. The home is always very clean, tidy and smells fresh. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 21 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): 27 28 29 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Sufficient staff are available at all times to meet the needs of people who live at the home. Staff do have all the skills to meet all the assessed needs of people who live at the home. People who live at the home are protected by the home’s recruitment practices. EVIDENCE: I observed that staff were able to effectively meet the needs of people living at home. People living at the home told me that staff are available to meet their needs. A person spoken to said, “ the staff are very good and understanding.” The rota showed that a consistent level of staffing is maintained on each floor. The registered manager explained that nine staff were on duty. The registered manager has maintained the same level of staff even though currently no permanent admissions are being made to home. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 22 I observed that staff were available at key times of the day (e.g. mealtimes) to assist people. Staff were also observed to spend time with people both individually and in small groups. This allowed more attention to the individual needs of people who live at the home. There is consistently enough staff available to meet the needs of people using the service. Staff spoken to told me that they had regular training. Staff felt that the training on dementia was particularly useful in helping them to understand the people. The registered manager explained the staff and been on an advanced dementia course. There were certificates available to confirm this. A relative said about the care of his mother that, staff understand her and her little ways.” Staff at the home had undergone training in all the statutory required areas. I was able to see certificates that confirmed that training had been provided. Staff spoken to confirmed that they had received training and this had made them confident in their ability to support the needs of people. The registered manager explained that further training was planned. A training plan was in place. This showed that training is planned to ensure that staff continue to be able to effectively meet the needs of people. The registered manager explained that at present 50 of staff have achieved the National Vocational Qualification in care. Staff spoken to felt that this training has given them important skills, which they use daily in their work with people who live at the home. One relative commented that, “ the care is very good.” The service puts a high level of importance on training to meet the needs of people. Currently no staff have been recruited to work at the home. Over the last three inspections it was found that approved recruitment procedures were followed. This included references, CRB checks and no unexplained gaps in the employment history of staff. Health checks had been carried out to ensure that staff were safeto work with people living at the Home. The service has a good recruitment procedure that clearly defines the process to be followed. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 23 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): 31 33 35 36 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate management structures are in place to ensure that people receive the care they need. People who live at the home are consulted about the quality of the service provided and are encouraged to make suggestions for improvement. People who live at the home have their financial interests protected by the home’s procedures. People who live at the home and staff are protected by the home’s health and safety procedures. EVIDENCE: Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 24 The registered manager has extensive experience of managing a service for older people and has maintained and updated her skills regularly. The registered manager explained that she had been on relevant training to update her skills. One relative said that the registered manager was approachable and, “ you can tell the manager and her team about anything that might concern you, she listens.” Staff spoken to told me they felt supported especially as the home was going through a period of change. A district nurse said, “ its a pleasure coming here, the manager has time for the residents.” The registered manager has a clear understanding of the key principles and focus of the service that works to make sure that people receive the care they need. The registered manager works to continuously improve the home and provide an increased quality of life for residents. She has completed a detailed annual quality assurance review and this provides a clear picture of how the service will be developed for the benefit of people living at the home. I have monitored monthly regulation 26 reports these show that the registered manager consistently addresses any issues where improvements may have been identified. Comment cards from people and relatives confirmed that they had been consulted and informed about changes to the service. Minutes of meetings with relatives and people who live in the home were seen and these confirmed their involvement in the running of the home. The registered manager explained that relatives are involved through the friends of Coppice Wood in raising money for the home. People and their representatives are consulted about the improvement of the service. The home has a system for obtaining the views of the quality of the service it provides and ensures that any areas for improvement are addressed. A survey of the views of people who live at the home, relatives and professionals was in place. A report highlighting the findings of the survey was seen. Actions to improve the service contained in the report had been addressed. Staff meetings are taking place to ensure staff are aware of plans to develop the service. The home does not hold money for people who live at the home. The home invoices their families or the relevant social service department for any expenditure made on their behalf. A system is in place to ensure receipts are obtained for any expenditure. Peoples money is kept securely and their financial interests are protected. Staff received regular supervision so that they can effectively meet the needs of people living at the home. I spoke with staff who told me that they had received supervision. They felt that this had been useful and enabled them to meet the needs of people more effectively. I saw that there were records of supervision sessions that had been held with staff. These had covered issues relating to the care of people living at the home and the development of the Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 25 individual staff members. The registered manager explained that annual appraisals take place so that staff received feedback on their performance. The home works to a clear health and safety policy all staff are fully aware of the policy and trained to put it into practice. Fire drills were taking place and the fire alarm was tested regularly. The system had been regularly checked. I found that the fire risk assessment included an assessment of all the potential fire risks in the home. I questioned staff on the fire safety procedures and found that they understood fire safety issues. At the last inspection it was identified that a number of fire doors were wedged open. These included the kitchen and laundry room doors. I walked round the home and found that no fire doors were wedged open. The registered manager was able to show correspondence that confirmed that the fire authority had been consulted about the use of magnetic door closure devices. I found that these had been installed. Staff spoken to understood the need to close fire doors. The safety of the people living at the home is maintained by the homes’ fire prevention systems and procedures. The home has a consistent record of meeting the relevant health and safety requirements and closely monitors its own practice. Regulation the 26 visit reports showed that any health and safety issues were dealt with promptly to improve safety for people who live at the home and the staff. Certificates for gas, legionella and electrical testing were in date. COSHH guidance was in place and chemicals were stored safely. Staff had all the necessary training on health and safety issues. I discussed health and safety issues with staff and they demonstrated their understanding. I also observed that staff followed appropriate guidance when carrying out moving and handling tasks with people living at the home. The home has an effective system for monitoring accidents to ensure the safety of people who live at the home. Regulation 37 notifications showed that any safety incidents involving people living at the home were reviewed. Appropriate measures are put in place to prevent the incidents from reoccurring. There were no discernible patterns of incidents found when recent regulation 37 reports analysed. All health and safety policies were available. The temperature of food delivered to and cooked was recorded. The temperatures of the fridges and freezers were recorded and within safe limits. Health and safety checks, procedures and training make sure that people living at the home are safe. Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 26 Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 27 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 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 3 X 3 Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 28 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 Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Office 4th Floor Aspect Gate 166 College Road Harrow, Middlesex HA1 1BH 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. Extracts may not be used or reproduced without the express permission of CSCI Coppice Wood Lodge DS0000030826.V351562.R01.S.doc Version 5.2 Page 30 - 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!
