Inspection on 11/08/05 for Copse Lea

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Copse Lea 11/10/08

Copse Lea 18/10/07

Copse Lea 06/03/07

Copse Lea 04/05/06

Copse Lea 20/12/05

Copse Lea 17/11/04

Copse Lea 26/05/04

Copse Lea 18/02/04

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

CARE HOME ADULTS 18-65 Copse Lea Tringham Close Ottershaw Surrey KT16 0NF Lead Inspector Sandra Holland Unannounced 11 August 2005 14:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Copse Lea Address Copse Lea Copse Lea, Tringham Close, Ottershaw, Surrey, KT16 0NF 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) 01932 873802 Welmede Housing Association Ltd Byfleet House, 2 Guildford Road, Chertsey, Surrey, KT16 9BJ Mr Suresh Bidessie Care home only (PC) 6 Category(ies) of Learning disability (LD), 6 registration, with number Learning disability over 65 years of age (LD(E)), of places 3 Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be 49 - 65 YEARS, AND WITHIN THE TOTAL NUMBERS UP TO 3 MAY BE OVER THE AGE OF 65 YEARS Date of last inspection 17 November 2004 Brief Description of the Service: Copse Lea is a residential home for up to 6 adults who have learning disabilities, three of whom may be over 65 years of age. The service is managed by Welmede Housing Association and the staff are employed by the North Surrey Primary Care Trust (NSPCT). The property is owned and maintained by Hyde Housing. The service is a detached property and the facilities and accommodation are set on two floors. There is no mechanical means to access the upper floor and none is required for the existing service users. All service users have a single bedroom and access to a separate lounge, dining room and kitchen. There is a large garden to the rear of the house and other garden areas to the front and side. The home is situated in a residential cul-de-sac in Ottershaw, which has a range of local facilities, including shops, post office, pubs and public transport. Copse Lea is adjacent to another home in the Welmede group (Pinewood), which is also managed by the registered manager of Copse Lea. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The inspection was carried out over seven hours by, Mrs. Sandra Holland, Lead Inspector for the service. Mr. Suresh Bidessie, Registered Manager was present representing the service. A full tour of the premises took place and a number of records and documents were examined, including individual plans, medication administration records (MAR), staff files and some health and safety records. All six of the residents and two members of staff were spoken with. The inspector wishes to thank the residents and staff for their hospitality and assistance. The people living at Copse Lea prefer to be known as residents and that is the term that will be used throughout this report. What the service does well: What has improved since the last inspection? Of the seven recommendations made at the last inspection only three have been carried out. The last wishes of residents are being obtained. Refrigerated food is now being labelled and dated when opened or disposed of if not required. A copy of the document “No Secrets” has been obtained. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 6 What they could do better: The home’s contract with residents need to be reviewed and revised. Resident individual plans need to be urgently reviewed and updated. Assessments of risks to residents need to be urgently reviewed and revised, particularly in relation to the toilet on the staircase. The administration of medication must be improved to ensure that the stock of medication held in the home matches the record held. The complaints procedure should be made available to all who may wish to use it. Record keeping in respect of residents’ finances must be improved to ensure residents are not at risk of financial abuse. The home should obtain a copy of the Surrey Multi-Agency Procedure for the Protection Of Vulnerable Adults. Storage facilities in the home should be reviewed to ensure there is adequate storage for items that are only seasonally required. The office space in the home should be reviewed to ensure that the residents’ lounge is not used by staff for the storage of documents and files. A review of the premises by an occupational therapist or other specialist has not been carried out. This was recommended because three of the residents are over the age of 65 years and their needs will be changing with age. Paper towels should be supplied and used instead of fabric towels, to prevent cross infection. A review of staffing in the home should be carried out to ensure that staff do not have to work excess hours or shifts. A Criminal Records Bureau (CRB) clearance must be obtained in respect of all staff who work at the home or apply to work at the home and a record of these must be held in the home. No one should be permitted to work unsupervised in the home until their CRB clearance has been obtained. Staff supervision must be carried out at the required frequency. The visitors book must be signed by all visitors to the home to ensure the safety of the residents and that of the visitors. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 7 Staff personal details must be kept in a locked provision. Substances hazardous to health must be stored in a locked provision. Fire doors must not be propped open. Restrictors fitted to ensure windows to ensure that they cannot be fully opened must be regularly checked and maintained. Antiseptic wipes must be provided for cleaning the food temperature probe. Opened packets of dry food items should be stored in sealed containers. 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. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5. Written statements of the terms and conditions of residence are provided to residents, but these do not contain all the required information. EVIDENCE: Residents are supplied with a Licence Agreement which specifies the terms and conditions of residence at Copse Lea. Those seen had not been signed by the resident or their representative, had not been dated and did not specify which room was to be occupied. The licence agreement also mentioned that the home provided insurance, but did not state to what level. The agreement did not state the full amount paid in respect of the resident or who would be paying or making contributions towards the residents funding. This information is not adequate. It is required that the licence agreement is reviewed and revised to include all the required information. A requirement has been made. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9. An individual plan is held for each resident and risk assessments have been carried out. Both of these documents need to be urgently reviewed and updated. EVIDENCE: Each resident has an individual plan, which was drawn up on admission and those seen had originally been comprehensive. These had now become very out of date and these no longer accurately reflect current resident need. It would be difficult for new staff or those returning after an absence, to establish the support needs of residents. Some entries in the individual plans are written as if spoken by the resident but the wording used, does not reflect the capabilities of the individual resident. The assessments in some areas of the individual plan are not adequate or very appropriate. Areas of risk to the health and safety of residents have been identified, assessed and recorded. Those assessments seen, had not been reviewed or updated for a long period. Risk assessments relating to specific needs were seen and these also need to be updated. Staff advised that one service user can be aggressive, but the most recent risk assessment relating to this was carried out two years ago. There is no risk assessment in relation to this Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 11 resident and the lone member of staff on duty at night. An assessment of the risks associated with residents’ use of the toilet on the staircase has not been updated from the date it was originally carried out, a year ago. Residents’ use of the toilet on the stairs is a known hazard and has already resulted in a resident having a very serious accident resulting in a major injury. The manager stated that residents are aware that they should not use the toilet, but no precautions are in place to prevent them. The manager also stated that he was waiting for CSCI to come to the home to tell him what action should be taken. This is unacceptable and actions must be taken by the registered manager to safeguard the residents living in the home. Requirements have been made. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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 17. Staff provide support to residents to develop their skills and to lead active and fulfilled lives. EVIDENCE: Residents were seen being supported to carry out household tasks, including clearing the dining room table and washing up. Residents who were able, advised that they are supported to be as independent as possible. The residents talked the variety of classes and activities they attend and two of the residents told of working at local establishments and attendance at local churches. Staff advised that residents are encouraged and supported to be independent and make choices in as many aspects of their lives as possible. On resident spoke enthusiastically about his trip to an air display on the south coast, which he had attended on the day of inspection. On his return, he displayed his souvenirs of the trip, which he was planning to add to his collection. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 13 A programme of activities has been drawn up for one resident and this was seen displayed on a notice board in the laundry room. Residents were seen enjoying their evening meal and stated that they enjoy their meals at the home. Meals are served in a family style in the dining room, which is comfortably furnished and adjoins the kitchen. Support for those residents needing assistance was given sensitively. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. Service users receive appropriate personal support. Their healthcare needs are well met. EVIDENCE: It was clear from observing residents and staff together, that personal support is provided according to the needs of the individual and in the way that the residents prefer. Personal support was given sensitively and discreetly and residents were spoken to in a respectful manner. From the individual plans and speaking to residents, it was evident that a number of healthcare professionals are involved in their support. These include general practitioners (G.P.’s), chiropodists, dentists and hospital specialists. Medication administration at Copse Lea is recorded on Welmede organisational MAR charts. These were seen to have a photograph attached of the resident to whom the record chart related. The manager advised that medication is supplied to the home by a local pharmacy in original packets and bottles. Receipt of medication into the home is recorded on the MAR chart on arrival. On examining the stock of medication in the home and the record held, it was not possible to check that these matched, because there was no indication as to when some supplies of medication had been started. This is not acceptable Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 15 and systems must be put in place to enable an audit trail of the administration of medication to take place. A requirement has been made. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. A complaints procedure is available in a format to suit residents’ needs, but is not freely available. Residents’ finances are not being adequately protected by the home’s record keeping. EVIDENCE: A complaints procedure is maintained in the home and is available in a pictorial format. The complaints record was seen and no complaints were recorded. The complaints procedure and record are both stored in a file in the upstairs office. It is recommended that the complaints record and procedure be made available in a communal area, to all who may wish to use it. The manager displayed the “No Secrets” document that the home was recommended to obtain at the last inspection. It was noted that this was being held in a file labelled Surrey Multi Agency Protection Of Vulnerable Adults. The original contents of the file were not present and the manager stated that he did no know where they were. It is recommended that the home obtain an up to date copy of this procedure, in order that staff know how to respond in the event of any allegation of abuse or serious incident affecting residents. Staff advised that resident’s monies held for safekeeping are recorded individually and checked three times a day at the staff shift handover. The record should be signed by two members of staff, one from the outgoing shift and one from the incoming shift to protect residents and staff. A number of shortfalls in the required standard of record keeping and handling of monies were noted: • It was noted that on some occasions, the checking of the monies have been carried out by one person, who has signed twice. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 17 • • • On checking that the amounts held matched the record held, it was noted that staff had signed to confirm the presence of an amount of money that was not actually present. An undated, slip of paper left in one resident’s cash box stated that a large sum of money was ”locked away”. The slip had been signed by a member of staff, but gave no indication as to where the money was or when it was removed. No entry had been made in the resident’s petty cash record book of the amount “locked away”. A receipt which recorded money paid to the hairdresser, had not been signed by the hairdresser, but by two members of staff. Record books of residents’ finances were seen retained in the main lounge of the home. These actions are unacceptable and must be changed as they leave residents open to the risk of financial abuse. To protect residents, more robust systems of record keeping and storage must be put in place. A requirement has been made. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28 and 30. The overall decoration and furnishings in this home provide a comfortable environment for residents. Some improvements are required to make it more homely, accessible and safe. EVIDENCE: A number of areas of the home, including the main hall and the outside of the home, were in the process of being decorated at the time of inspection. The home was bright, cheerfully decorated and comfortably furnished, in a domestic style. Portable, electrical heaters were seen in a number of rooms on the ground floor. Staff advised that these are used to supplement the central heating system in winter. It is required that these are stored appropriately when not in use. A number of adaptations have been made to the house to support residents. The manager stated that resident’s needs are assessed individually and adaptations made as required. The recommendation made at the last inspection, that a specialist assessment of the whole property in relation to the needs of ageing residents, is carried out, has not been done. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 19 It was clear that staff use the resident’s lounge as a secondary office. A number of record books and files of policies and procedures were seen in use on the coffee table and side tables. A cupboard in the corner of the room is used to store files and a member of staff had left a handbag and personal items in the room. This is not acceptable and arrangements must be made for more appropriate use of the office space available and for staff to store their belongings safely, whilst on duty. A large garden surrounds the home, with access from the house via a ramp, fitted with handrails. The garden is mostly level, but some areas of the patio around the house have different levels, which would prohibit free access to residents using wheelchairs or with mobility problems. The manager stated that it is planned to make the patio area fully level next year. The home was seen to be clean and freshly aired. It was noted that fabric towels are used in the kitchen and bathrooms, which are changed daily, staff advised. It is recommended that paper towels are supplied and used, as these reduce the risks of cross infection. Requirements and a recommendation have been made. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 36. The support needs of residents are met by a small team of staff. Recruitment practices need to be more robust. Supervision of staff needs to be given a higher priority. EVIDENCE: A small team of support staff are employed to meet the needs of the residents. Staff advised that they all share the support tasks involved, including personal care, shopping, cooking, household tasks and laundry. From examination of the rota and speaking to staff, it was clear that some staff have been working a large number of hours or shifts each week. Whilst this ensures continuity of support for residents and reduces the need for agency or bank staff, it is not advisable long term. Working excess hours may affect the health of staff or their effectiveness and safety when at work. The manager was asked if staff have signed a Working Time Directive disclaimer, but he seemed unaware of what this was. A disclaimer regarding the Working Time Directive, when signed by staff, would indicate that they have agreed to work hours in excess of the recommended number, and have not been made to work them. Most of the staff working at the home have been employed there for a number of years, so few staff have been recruited recently, the manager stated. It is Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 21 of concern however, that no record was held or available in the home to show for which staff, Criminal Record Bureau (CRB) clearances had been obtained. The manager stated that supervision of staff takes place approximately three or fours times a year for some staff and at variable times for others. The manager stated that he had difficulty locating the supervision records. Those eventually seen, indicated that some staff had received supervision once recently, but previous records were dated from one or two years ago. It was noted that some supervision records were in the handwriting of the staff member who had signed them, the comments recorded were minimal and no comments written by the supervisor. It was of concern that three supervision forms, completed by a member of staff were seen in the resident’s lounge, alongside a diary and bag. The member of staff named confirmed these belonged to her. The forms were undated and had not been signed by the supervisor. Requirements and a recommendation have been made. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41 and 42. The home needs much stronger and more effective management. EVIDENCE: The manager stated that he is qualified as a nurse for people with learning disabilities and that he has managed the home for approximately ten years. He advised that he returned to the home earlier this year following an absence of nearly a year due to ill health. The manager advised that he has been enrolled to undertake the National Vocational Qualification (NVQ), Registered Manager’s Award (RMA), but has yet to commence. The manager stated that he also manages another home, run by the same organisation, which is situated in the adjacent property. The manager was present at the time of inspection and provided much of the information required. In discussion, he did not appear to be aware of the seriousness of the shortfalls noted in the standards of the home’s record Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 23 keeping, maintenance and staffing issues. The manager made repeated comments to the inspector that he was waiting for CSCI to come to tell him what to do. The office arrangements in the home are not effective. An upstairs bedroom has been appointed as an office, but is not fully furnished as such. A computer has been provided in this room, but is not connected and the door was seen wedged open, despite having a fire safety automatic closer fitted to it. A very small “room”, next to the appointed office, was previously the office, but is really too small to sit in. As noted previously, many files and documents, which should be stored in the office, are being inappropriately stored in the resident’s lounge. The number of the shortfalls in the required standards and the number of requirements and recommendations, all indicate that the home is not being competently managed. There is no evidence of management planning or of a sense of leadership, direction or acceptance of responsibility. Record keeping in the home does not meet the required standard. Files containing staff personal details were seen on open display in the office upstairs, although a filing cabinet was available. A recommendation was made at the last inspection, that all visitors to the home are required to sign the visitor’s book. This is to ensure the safety of the residents and to ensure that staff are made aware who is on the premises in the event of a fire. On arrival, the inspector was not asked to sign the visitor’s book and when it was examined, the last entry had been made four months ago. A number of shortfalls in the required standards, which may affect the health and safety of residents were noted: • Substances hazardous to health, were stored in unlocked cupboards in the kitchen and laundry-room. • Fire doors, which were fitted with automatic closers were seen to be propped open in the laundry-room, the upstairs office and a resident’s bedroom. • Window restrictors are fitted to upstairs windows but some are not effective. • No antiseptic wipes were available, with which to clean the food temperature probe. • Open packets of dried foods were not stored in sealed containers. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 1 x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x 2 1 x 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Copse Lea Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 1 1 x x 1 1 x H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 25 Are there any outstanding requirements from the last inspection? Recommendations are outstanding. 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 5 Regulation 5(1) (b)& 17(2) Schedule 4 (8) Requirement The registered person must produce a statement of the terms and conditions in respect of accommodation to be provided for residents, including as to the amount and method of payment of fees; and a standard form of contract for the provision of services and facilities by the registered provider to residents; this statement/contract to be specific to each individual resident. The registered person shall keep the residents plans under review. The registered person shall ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall maintain in the care home the records specified in Schedule Timescale for action 11th November 2005 2. 3. 6 9 15(2)(b) 13 (4) 9th September 2005 9th September 2005 With immediate effect from 11th August 2005 9th September 2005 Page 26 4. 20 13 (2) 5. 23 17 (2) Schedule 4 Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 6. 24 7. 33 8. 34 9. 36 10. 37 and 38 4.9(a) and (b) in respect of residents monies held for safekeeping. 23(2)(l) The registered person shall having regard to the number and needs of the residents ensure that suitable provision is made for storage for the purposes of the care home. 18 (1)(a) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the residents, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of the residents. 19 (1)(a & The registered person shall not b) employ a person to work at the care home unless- (a) The person is fit to work at the care home and (b) The information and documents specified in Schedule 2 have been obtained in respect of that person. Specifically, no person must be permitted to work unsupervised if a CRB clearance has not been obtained in respect of that person. 18 (2)(a) The registered person shall ensure that ppersons working at the care home are appropriately supervised. 9(2)(b)(i) A person is not fit to manage to and 10 manage a care home unless, (3) having regard to the size of the care home, the statement of purpose, and the number and needs of residents, he has the qualifications, skills and experience necessary for managing the care home. The registered manager shall H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc 9th September 2005 9th September 2005 With immediate effect from 11th August 2005 9th September 2005 11th November 2005 Copse Lea Version 1.30 Page 27 11. 41 17 (2) Schedule 4.17 and 17 (3)(a) 12. 42 16(2)(g) 13. 42 13 (4)(a)and (c) undertake from time to time such training as is appropriate to ensure that he has the experience and skills necessary for managing the care home. The registered person shall maintain in the care home the records specified in Schedule 4 and shall ensure that the records are kept up to date. Specifically, a record of all visitors to the care home, including the names of visitors, must be maintained. The registered person shall provide sufficient and suitable kitchen equipment, crockery, cutlery and utensils, and adequate facilities for the preparation and storage of food. The registered person shall ensure that (a) All parts of the home to which residents have access are so far as reasoably practicable free from hazards to their safety and (b) Unnecessary risks to the health or welfare of residents are identified and so far as possible eliminated. 9th September 2005 9th September 2005 With immediate effect from 11th August 2005. 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. 2. 3. 4. Refer to Standard 22 23 28 30 Good Practice Recommendations It is good practice to make the complaints procedure and recording log, available to all who may wish to use it. It is recommended that the home obtains a copy of the Surrey Multi-Agency Procedure for the Protection Of Vulnerable Adults and retains this in an accessible place. It is recommended that more appropriate storage is arranged for the records and documents currently stored in the residents lounge. The use in the home, of paper towels, is recommended to prevent cross infection. H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 28 Copse Lea 5. 6. 7. 41 It is good practice to ensure that all personal information in relation to staff is stored in a locked provision. Not applicable. Not applicable. Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Copse Lea H09 H58 S13610 Copse Lea V224417 110805 Stage 4.doc Version 1.30 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. 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