Inspection on 18/10/07 for Copse Lea

This inspection was carried out on 18th October 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copse Lea 11/10/08

Copse Lea 06/03/07

Copse Lea 04/05/06

Copse Lea 20/12/05

Copse Lea 11/08/05

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 Copse Lea Tringham Close Ottershaw Surrey KT16 0NF Lead Inspector Suzanne Magnier Unannounced Inspection 18th October 2007 12.15 Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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 Copse Lea DS0000013610.V338982.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 Adults 18-65. 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. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Copse Lea Address Copse Lea Tringham Close Ottershaw Surrey KT16 0NF 01932 873802 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) penny.lamb@surreypct.nhs.uk Welmede Housing Association Ltd Penelope Lamb Care Home 6 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability – (LD) 2. Learning disability, over the age of 65 years – (LD(E) The maximum number of service users to be accommodated is 6. Date of last inspection 6th March 2007 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. Welmede Housing Association manages the service and the North Surrey Primary Care Trust (NSPCT) employs the staff. 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 residents. All residents 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 acting manager of Copse Lea. Fees are £1,039 per week. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager represented the service. For the purpose of the report the individuals using the service are referred to as people/residents. The inspector arrived at the service at 12.15 and was in the home for three and a half hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the homes manager, and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home in order to seek their views about the home and the care they receive. The commission had not sent out written comment cards as views and opinions regarding the service had been sent out during the last inspection in March 2007. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, care/person centred plans, daily records and risk assessments, medication procedures, staff recruitment profiles, staff training records, and health and safety records. Following a previous key inspection in March 2007 all but one requirement has been met. This was addressed during the inspection and evidence sampled that the manager had referred the detail to the Housing Association. The home has submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the people living in the home and the staff for their time, assistance and hospitality during this inspection. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Prospective residents have sufficient information to make an informed choice if they would like to live in the home, which includes trial periods of stay in the home if they choose. Arrangements are in place for a care needs assessment for individuals to ensure that their needs are assessed and identified before admission to the home. EVIDENCE: The inspector sampled the homes Statement of Purpose and Service User Guide, which the manager had updated since the previous inspection. The documents included a description of the standard services offered by the home and the fees payable with the inclusion of arrangements for charging and paying for any services additional to the standard service for example staff support. The manager explained that in order to meet the diverse needs of all residents the Service User Guide had been developed using symbols and photographs of the home and was written in a way, which was easy to read and understand. The inspector sampled a document entitled ‘my money’ which Welmede Housing Association had developed to clearly set out each person’s financial Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 9 entitlements, what their rent covers and their personal allowance the services provided by the home. The inspector was advised that there have been no admissions to the home since the last inspection. Throughout the inspection the manager demonstrated the knowledge and ability to ensure that the homes admission and assessment procedure would be implemented for a person who wanted to move to the home to determine that the care home could meet the needs of the individual. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home has robust care plans and risk assessments. The documents were well recorded to ensure that the residents changing needs, safety and wellbeing were being met. People make decisions regarding their life and participate in the running of their home. EVIDENCE: The inspector sampled two care plans. Both of the care plans were noted to be well written and clear to demonstrate the care needs of the individual. One care plan had been redeveloped to include a more person centred approach and the manager explained that all care plans are being redeveloped over the coming months. The redeveloped care plan detailed the individuals preferred choice of name, their significant others and friends contact details, the individuals hobbies, likes and dislikes, how the individual communicates, what objects, places or people are significant in their lives, their personal history’s and what support and Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 11 assistance they would like and need from staff. Agreed working guidelines were also in place to offer individuals a consistent and supportive plan of care. The inspector observed staff openly engaging with individuals and listening to what individuals had to say and supported decisions in their lives for example one person at the home told the inspector that they wanted to live in their own flat and the manager explained that the home had supported the individual explore this choice about their life and where they wanted to live. Several of the residents told the inspector that they liked their home and felt happy. It was noted that the home has a notice board with a variety of useful information and also a duty rota which includes staff photos in order that residents are aware who is in their home to support them. The home have a suggestion box for the residents and all people who visit the home in order that they can express their views and opinions anonymously. Whilst sampling the care plans the inspector noted that there were agreed working practices and well documented risk assessments available for all staff to follow when supporting people with their personal care, mobility, support with meals, using the wheelchair and when out and about away from home and for any individual hazard identified in the individuals daily living. The daily records written by staff were well written and documented clearly the support and care the person had received and how they had spent their day. The AQAA received by the commission states that the home has a key worker system and two residents have chosen not to have a key worker. Evidence of reviews of care plans was sampled in order to ensure that the changing needs or support the individual requires is documented and the individual’s needs are met. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home promotes and maintains individual’s involvement in their local community and offers opportunities for personal development, appropriate activities and employment and assists in maintaining and supporting friendships. People are encouraged to be involved in the running of the home and maintaining their daily living skills. A choice of a healthy diet is provided. EVIDENCE: One resident told the inspector that he had been down the pub and showed the inspector his bedroom, which had a variety of his personal possessions, which included model aeroplanes, books, DVD’s and other leisure items. Another resident was in her room following lunch and enjoying some quiet time, she told the inspector that her mother had visited her recently. The inspector sampled the monthly resident meeting minutes, which are typed by staff and pictures of the topics discussed form part of the minutes. Each Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 13 resident’s comments are written in a different colour so they can see what they said during the meeting. The staff have been actively involved in improving leisure and recreational opportunities for residents. These have involved supporting residents to new activities for example an evening club which the residents told the inspector they really enjoyed, having a ladies night and gents night get together with a neighbouring home. An independent person visiting the home to undertake one to one activities for example crafts such as making collages, model aeroplanes, scrap books, carousels and train sets. Other activities include a drama group and one resdident has therapeutic employment with the local authority. The AQQA received by the commission details that the home hopes to have involvement with local day centre to play darts. The manager explained that the improvements in the homes activities have been beneficial to resident’s confidence and self esteem which was evident that one resident is encouraged to ring the hairdressers and make their own appointment and all residents now visit the local hairdresser rather than having their hair cut at home. The home has registered with the Dial-A Ride which has enabled residents to travel further afield. One resident has an advocate and comments received by the home were extremely favourable and noted that the manager and staff had made significant improvements to the quality of the residents life. Several residents told the inspector that they have family and friends who are encouraged to visit and meet with their relative or friend in private if they wish too. Residents cultural and religious beliefs were respected by staff and included supporting some residents to attend church independently. Several residents are involved in the running of the home, which includes gardening, cleaning, helping to lay the tables and shopping. The inspector observed one resident supporting staff making the evening meal by peeling the potatoes. The inspector noted that staff respected residents privacy by knocking before entering any bedrooms, adhereing, where possible to gender specific care and offering personal care in a respectful manner. The homes fridge was well stocked with fresh dairy products and vegetables. The residents were enjoying their midday meal in the dining room having been in town during the morning. The meal consisted of a variety of choice, which the residents told the inspector was lovely. The inspector sampled the homes menu, which demonstrated that a varied choice and nutritional diet was offered. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home has consistent recording and documentation to evidence that residents attend health care appointments to ensure their wellbeing and welfare. The homes medication procedures are robust to ensure the safety and wellbeing of all people in the home. EVIDENCE: The person centred plan developed by the home clearly documents the ways in which the individual prefers to have their personal care needs attended. The plan included a twenty-four hour breakdown of the resident’s lifestyle and routine, which includes the support from staff by using objects of reference. The health action care plan clearly documented the resident’s needs of and included appointments to the optician, chiropody, dentist, speech and language therapy and GP appointments. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 15 Whilst sampling records it was evident that the home has links with visiting healthcare professionals. The manager explained that a dietcian referall has been made by the home and the home are awaiting the delivery of weighing scales in order that residents body weigh can be measured. The home have ongoing support from the dementia care team and this is reviewed every three months with the speech and language therapist and the dementia specialists to ensure the ongoing support of the resident. The medication cupboard is located in a safe place within the home and is locked to ensure security and safety. The home has a medication policy and procedure, which has recently been reviewed. The inspector sampled the medication administration charts and noted that staff administering medication initialled them and all staff have completed medication assessments. Each residents medication administration chart contained their photograph. The home have gained written authorisation from the residents GP to administer homely remedies. The manager explained that the home does not have any residents on controlled drugs yet explained the system for accounting and the documentation required for the safe storage and administration of controlled medication. Whilst sampling the residents care plan it was noted that the staff had attained the views and choices of the resident with regard to wishes at the end of their life. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People living in the home are encouraged to able to express their concerns and have access to a complaints procedure and are protected from abuse and have their rights protected. EVIDENCE: The home has a clear complaints procedure, which has also been adapted in differing formats for people living in the home. The inspector sampled the resident’s complaints procedure and noted that it included pictures and symbols as well as written text and included the CSCI Oxford address. Copies of the complaints procedure were also noted to be available throughout the home. The AQAA indicates that no complaints had been received since the previous inspection. The manager explained that if the home were to receive a complaint it would be logged within the Quality Assurance documentation. It has been recommended that a separate complaints log be developed in order that there is a detailed clear chronology of events for example dates and details of correspondence and outcomes regarding complaints received by the home. The inspector sampled that the home has the local authorities multi agency procedures for safeguarding adults and the manager advised that the home follows these procedures and thus do not have a local policy. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 17 The AQAA and the manager stated that there had been no safeguarding referrals under the safeguarding adults procedures. The inspector noted that the home has a whistle blowing policy and procedure, which is available to staff in order to safeguard people in their care. Training records detailed that staff receive safeguarding adults awareness training. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 30. Quality in this outcome area is poor. This judgement has been made using a range of evidence including a visit to this service. Improvements must be implemented to provide residents with suitable bathing facilities, adequate heating and a safe environment. The home is clean, pleasant and hygienic throughout. EVIDENCE: During the tour of the premises the inspector noted that the home was well decorated. Special attention had been made to promote a pleasing environment with homely ornaments and décor and new carpets throughout the hallways and communal areas had been laid and new lounge furniture had been ordered. The home was clean and free from malodour. The laundry area was orderly and clean. Hand washing facilities were available throughout the home. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 19 Resident’s bedrooms were well decorated, clean and comfortable and it was observed that aids for mobility were available for residents to use to help them move freely around their home. During the inspection in March 2007 the inspector had reported that two resident’s preferred to have their bedroom doors wedged open. Whilst undertaking the tour of the premises the inspector observed that the door remained wedged open and the requirement that a suitable system must be installed to ensure the doors would automatically close if the fire alarm sounded had not been met. The inspector raised concern that the requirement had not been met and was assured by the manager that financial quotes had been obtained regarding having sensory door controls fitted. The inspector sampled the quotes and the correspondence made by the home and a further requirement has been made that when fire doors are kept open for the convenience of the residents and the staff a safe system must be in place to ensure they close in the event of a fire alarm. The bathing facilities in the home were discussed and it was noted that only one bath was currently in use. On investigation the manager explained that the assisted bath had been out of order for several months and a new bath had been requisitioned. The arrangements for resident’s to bathe had been addressed by staff supporting residents to use a neighbouring care home yet one resident had not had a general bath for several months. The manager fully understood that this practice was unacceptable and it was evident by sampling electronic mails and other purchasing orders that she had consistently chased up the order to confirm that the bath would be installed. A requirement has been made that the home provides sufficient baths/showers with a hot a cold water supply to meet the needs of the residents. The inspector observed a freestanding radiator in the corridor and the manager explained that the area by two residents bedrooms and bathroom was cold and this was confirmed during the inspection. A requirement has been made that the home ensures there is adequate heating in all parts of the home, used by residents. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Staff are trained and skilled to provide 24-hour support to residents in their home. The home has a robust system for the induction, training development and recruitment of staff to ensure that individuals needs are met appropriately and safely. EVIDENCE: The home currently employs six care staff and two bank staff with one staff member having transferred from another Welmede service and has been employed since 1994. On the day of the inspection there were two care staff on duty with the manager. All staff were observed as skilled in supporting the residents in their care and were knowledgeable regarding the specific needs of individuals to ensure their safety and well-being. The home has a recruitment and selection policy, which incorporates equal opportunities. The inspector sampled the staff member’s file that had been transferred to the home and CRB checklists for all staff had been obtained. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 21 It was noted that the staff have individual training files. Records indicated that staff had received mandatory training and the manager explained that training was always available from the PCT. The manager has made significant effort to address the shortfalls regarding staff training and awareness in matters concerning resident’s rights to choice, involvement and participation in their own lives for example relearning lost skills and finding new skills in everyday living. All staff have attended Equality and Diversity training. The manager advised that she had implemented a staff induction programme for all prospective staff who commence working at Copse Lea. The AQAA advised that two out of the six staff have achieved an National Vocational Qualification Level 2 and 2 staff have enrolled to undertake the qualification including the deputy manager. The manager advised that she has reviewed the staffing availability in the home and has employed bank staff, which has promoted residents to have more social interests and planned activities. The manager has submitted a statement of need for extra staffing and increased staffing levels to meet the residents needs. The statement is curently with Welmede Housing association. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The management and administration of the home is robust and the home is run in the best interests of the residents living in the home. The home has a quality assurance process to seek the views of people connected with the service. Health and safety aspects need to be improved to ensure the welfare and wellbeing of the residents. EVIDENCE: The home have been without a formal manager since November 2006 until January 2007 and it was acknowleded that the deputy had been undertaking the day to day running of the home in the absence of a registered manager. The homes manager was registerd with CSCI in January 2007 and has Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 23 undertaken the Registered Managers award and has achieved the National Vocational Qualification Level 4. She is also a trained National Vocationsl Qualification (NVQ) Assessor. During the course of the inspection the inspector noted that the pace of the home was designed to meet the needs of the residents living in the home. It was evident through observation and talking with residents that the manager had good knowledge about managing the care home and had the skills and experience to ensure the safety and well being of all persons in the home. The inspector was made aware that the current manager is managing two registered care homes and the workload to improve the services was discussed during the inspection. It is advised that this practice should be reviewed to enable the service to be more effectively managed by one person on site in a full time capacity. The manager explained that the home and staff are committed in improving the service to meet the needs of the residents and this was evidenced during the inspection. Staff have found it difficult to embrace the changes needed in the home yet have begun to work as part of a team and have been involved in staff meetings, teamwork to increase their confidence and awareness, additional training, supervision, performance management and the updating of residents care plans to include a more person centred approach. A letter received by the home stated that the manager ‘has regularly informed and encouraged her staff to update their skills and knowledge, so that they respond to the residents needs with care, respect and dignity at all times. This is something that is closely monitored by the manager’. ‘ Being welcoming and friendly to visitors to the home and courteous on the phone has certainly improved’. Two residents financial records and money held in the home were sampled and records evidenced accuracy in safeguarding people’s final affairs. All the residents are in receipt of their personal allowance to spend as they choose and records and receipts were available for inspection. The inspector was advised that the ledgers are regularly audited by the organisation and have been randomly scrutinised by an outside auditors. A written comment received by the home regarding a residents finances indicated that the manager and staff had made ‘great progress’ in sorting out an individuals finances and benefits and this has promoted the individuals access to their local community and avoided them becoming isolated. The home has a vehicle, which is shared by a neighbouring home. The home have undertaken a documented risk assessment, which includes actions to be Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 24 taken in the event of a vehicle breakdown, emergency contacts and vehicle maintenance records in order to ensure that people in the vehicle are safe. People’s views about the service were sought and the inspector sampled some comment cards that had been sent out to people associated with the home. The manager explained that the findings will be sent to Welmede Head Office and collated and feedback is then given to the service. During the tour of the premises the inspector went into the bathroom/toilet, which was being occupied by a resident. The inspector observed that there was no sign on the door to indicate that the room was occupied and a recommendation has been made that signs indicating ‘vacant and engaged’ are displayed on the bathroom/toilet doors to help promote peoples rights to dignity and privacy. The home undertakes health and safety checks and has infection control measures in place. The accident and incident book was sampled and evidenced that the home have reported the the CSCI under Regulation 37 notifications events that affect the well being and welfare of individuals in the home. The outstanding requirement regarding the fire doors has been documented in a previous section of the report and the requirements relating to adequtae heating and bathing facilities must be met within the timescales set in order to ensure the wellbeing and welfare of the residents. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 X 3 X X 2 X Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA24 Regulation 12. (10) (a) 13. (4) (a) Requirement When fire doors are kept open for the convenience of the residents and the staff a safe system must be in place to ensure they close in the event of a fire alarm. Timescale for action 19/11/07 2 YA24 23.(2)(p) 3 YA27 23. (2)(j) 4 YA37 24A Timescale not met 01/05/07 The home must ensure 19/01/08 there is adequate heating in all parts of the home, used by residents. The home must provide 19/11/07 sufficient baths/showers with a hot a cold water supply to meet the needs of the residents. The home must submit an 29/11/07 improvement plan setting out the methods and timescales of how the home intends to improve the services provided in the care home. Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 27 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 YA22 Good Practice Recommendations It has been recommended that a separate complaints log be developed in order that there is a detailed clear chronology of events for example dates and details of correspondence and outcomes regarding complaints received by the home. It has been recommended that signs indicating ‘vacant and engaged’ be displayed on the bathroom/toilet doors to help promote peoples rights to dignity and privacy. 2 YA42 Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Copse Lea DS0000013610.V338982.R01.S.doc Version 5.2 Page 29 - 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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