Inspection on 04/05/06 for Copse Lea

This inspection was carried out on 4th May 2006.

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 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 13 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 18/10/07

Copse Lea 06/03/07

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Copse Lea Copse Lea Tringham Close Ottershaw Surrey KT16 0NF Lead Inspector Suzanne Magnier Unannounced Inspection 13:00 4th May 2006 Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 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.V289057.R01.S.doc Version 5.1 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 and 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.V289057.R01.S.doc Version 5.1 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) Welmede Housing Association Ltd Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (3) of places Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 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 20th December 2005 Date of last inspection 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 DS0000013610.V289057.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Unannounced inspection took place over four and a half hours and was conducted with the deputy manager who was also the shift leader. The acting homes manager Registered Manager was not available as he was on holiday. For the purpose of the report the inspector was advised that the people who live in the home are referred to as residents. Part of the focus of the inspection was to assess the standards not inspected at the last inspection in December 2005. A tour of the premises was undertaken. The inspector met with all the residents. Due to the complexity and communication abilities of some of the residents the inspector made judgements against observations and verbal communication with residents. Comments from residents have been included within the report. The home had supplied CSCI with a pre inspection questionnaire details of which have also been included within the report. Files sampled included residents care plans, risk assessments, a variety of the homes policies and procedures, staff training records and resident activity records. The inspector was unable to access the staff recruitment files due to the absence of the acting manager. The feedback following the inspection was given to the deputy manager. The inspector wishes to thank the residents and staff for their cooperation during the inspection. What the service does well: What has improved since the last inspection? Significant improvements have been made to all the residents care plans and risk assessments. The care plans sampled evidenced a significant improvement regarding the documentation of the resident’s preferences regarding receiving personal care. The guidelines were simply written and easily understood and demonstrated dignity and choice for the resident. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 6 Improvements to the record keeping of resident’s finances were noted and the records sampled were well documented and accurate. The home was clean and hygienic throughout, several areas of the home had been newly decorated and all resident’s rooms were viewed as comfortable and individualised. What they could do better: It has been required that Welmede Housing Association appoint a person who has the day to day management responsibilities of the home. There are a high proportion of statutory requirements of serious concerns, which remain outstanding from previous inspections and these must be complied with in accordance with the Care Homes Regulation (as amended) 2001. There remain shortfalls regarding Welmede Housing Association and the care home ensuring that residents or their representatives are fully informed regarding the services and facilities offered by home. Requirements made during the previous two inspections have been partly met however the inspection highlighted a shortfall in information for residents or their representatives regarding the way in which rent is paid, the details of which must be included in the residents care plan. The homes Statement of Purpose and Service User Guide require updating and the shortfalls discussed with the deputy manager. A copy of the amended Care Homes Regulations 2001 have been forwarded to the deputy manager. Recommendations have been made regarding the monitoring of behaviour which the challenges the service. One resident, due to their disabilities are not included in meaningful activities and an immediate requirement has been made that this matter is addressed. The homes menu must also be further developed to detail meals provided to each resident and offers of choice. A requirement has been made that all homely remedies are authorised by the residents GP prior to staff administering these to residents. The homes complaints procedures required updating and revising to ensure that any persons wishing to make a complaint regarding the service provided could do so and complaints would be acted upon. The inspector noted from the staff training files that only one staff member out of five had received training in the Safeguarding of Vulnerable Adults in order to ensure that the home promotes the rights of residents to protection. The training record indicated that the four staff would be attending the necessary training on the 15.05.06. An immediate requirement was made that all staff Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 7 receive training to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. A requirement has been made that the Registered Person investigates the matter of residents paying for staff to ‘escort’ them. The arrangement must be confirmed in writing by the resident and their representative and this record, including other additional services not covered in the fees must be available on the residents care plan. CSCI must be informed in writing of the outcome in order to ensure measures are in place to protect residents from abuse or being placed at risk of harm or abuse. There were shortfalls regarding staff training, induction and recruitment checks. A review and assessment of the care and support needs for one resident with Dementia was also needed in view of the shortfalls in staff training in understanding and awareness of Dementia. It is recommended that the Registered Person attain a copy of the Department of Health, White Paper Valuing People for staff information and guidance. Improvements were required in respect of reorganising staff duty rosters and the hours worked by staff to ensure accuracy. The homes insurance certificate, in respect of liability, displayed in the hallway had expired in March 2005. An immediate requirement was made that the Registered Person must ensure that the homes insurance certificate, in respect of liability, is up to date and available for inspection. On the previous inspection on 20.12.05 the requirement that a system be implemented to review the quality of care and seek service users, or their representatives views and opinions of the service provided had not been met by 10.3.06. A further immediate requirement was made that the Registered Person must establish and maintain a system for reviewing and improving the quality of care provided at the care home. 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 DS0000013610.V289057.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information provided by the home was in need of updating including the Statement of Purpose and Service User Guide. Clearer information was needed in respect of the fees paid by residents. EVIDENCE: The deputy manager told the inspector that there have not been any admissions to the home since the last inspection in December 2005. The home does not offer intermediate care. The certificate of registration documented the previous registered managers details and a requirement has been made that the home obtain an updated Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 10 certificate of registration, which reflects the current management arrangements of the home. Following the previous inspection the home has partly met the requirement regarding documented information of the costs of services and facilities offered by the home. A document sampled by the inspector included the cost of staffing, household services, utilities, food budget, costs of the service vehicle, medical supplies, management costs and advocacy. Five out of six residents files contained the information. The inspector sampled a letter in each residents file which advised the resident of an increase in the rent however there was no evidence within the resident’s files to inform them or their representative how the rent was paid and by whom for example if social services and the resident partly paid the rent. A requirement has been made that Welmede Housing Association clearly documents, for each resident how his or her rent is paid. The service user guide sampled did not relate to Copse Lea but another care home run by Welmede Housing Association. The Statement of Purpose was well documented and written in plain English, and included photos of the home, facilities and some services yet it did not include accurate details of the homes category of registration for example the mixed category of younger adults and older people and the current staffing details and arrangements. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,14,33. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Significant improvements have been made to all the residents care plans and risk assessments. Recommendations have been made regarding the monitoring of behaviour which the challenges the service. EVIDENCE: Several residents spoken with during the inspection told the inspector that they liked the home and staff were ‘nice’. The inspector sampled all the resident’s plans and it was noted that significant improvements to the recording and reviewing of the residents care plans had been made following the previous inspection. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 12 The care plans sampled were individualised and included photos, clear guidance for the reader regarding the resident’s lifestyle, preferences, and activities. Health care records were also sampled in the resident’s files, which included specialised healthcare appointments. The care plans had been signed by the residents, where possible and also all staff supporting the residents. The home have also made significant improvements in ensuring that documented risk assessments are available in the residents files which indicate identified hazards and precautions in place to ensure the residents safety and well being as far as reasonably practicable. The home is currently supporting one resident who has been diagnosed with advanced Dementia. The care plan, following the previous inspection included risk assessment regarding use of a wheelchair, a specialised hoist, and adapted bath. In order to assist the resident in their daily life specialised speech and language assessments have been implemented and include the use of objects of reference to assist the resident in understanding and communicating their needs to people supporting them. Whilst sampling the residents care plan the inspector spoke at length with the deputy manager and has recommended the use of behavioural monitoring charts (a.b.c.charts) which include the assessment of behaviour for example antecedent (what was happening prior to the behaviour), the behaviour being presented and the consequence of the behaviour including staff response and action taken. It is hoped this method of assessment would assist staff to understand more fully the links between the resident’s communication and behaviour. The inspector raised concern regarding the shortfall in staff training regarding supporting a resident with Dementia, which is more fully documented in Standard 32 of the report. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10,12,13,15,16,17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports some residents to maintain active, stimulating and meaningful activities in the community and encourages holidays and links with family, churches and Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 14 friends. One resident, due to their disabilities are not included in the activities and action is required in this area. The homes menu needs to be further developed to detail meals provided to each resident and offers of choice. EVIDENCE: The inspector met with all the residents. Two residents were at home during the day and the remaining 4 residents had been out either at work, to leisure activities including the cinema or attending organised day services. The deputy manager explained that some residents attend church, and are supported to go on holidays with staff support and links with family and friends are supported and maintained. The inspector sampled one residents care plan and noted that the resident was unable to access the wider community, for example being supported on holiday or visits to the coast with other individuals residing in their home due to the lack of appropriate transport facilities. On further examination it was noted that the previous inspection highlighted this shortfall and the requirement made had not been met by the 10/03/06. The Deputy Manager advised that Welmede Housing Association had been investigating the possible purchase of an appropriate adapted vehicle over the last year. It is required that Welmede Housing Association inform CSCI Eashing of the progress made in respect of this matter. The homes menus were sampled as part of the pre inspection questionnaire detail and fully discussed during the inspection. It was noted that the daily record of food provided was not accurate and did not reflect what the residents had eaten at the mealtime or if a choice of meals was offered. A requirement has been made that the menu be designed to accurately reflect choice, special diets and provide sufficient detail to determine that the diet offered is nutritious. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9,10,11,18,19,20,21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has made significant improvements in the documentation of the resident wishes and preferences regarding receiving personal care and choices regarding final affairs. Overall the medication arrangements were adequate with the exception of homely remedies and action has been required in this area. EVIDENCE: The care plans sampled evidenced a significant improvement regarding the documentation of the resident’s preferences regarding receiving personal care. The guidelines were simply written and easily understood and demonstrated dignity and choice for the resident. Health care records were evidenced during the inspection with additional specialist support from speech and language therapists, occupational therapists and care managers. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 16 The inspector sampled the homes medication procedure and policy, which had been reviewed in 2005. The medication stored in the home is stored in a locked room and staff receive in house training. The MARS sheets sampled by the inspector were evidenced as current with clear signatures and no gaps in the administration of medication. It was noted that staff were administering homely remedies for example Paracetamol without the GP’s consent and a requirement has been made that consent is obtained from the GP prior to any medication being administered by staff. Medications received into and returned to the Pharmacy were documented on the MARS sheets and also the returns book, which the pharmacist had signed. Within each resident’s care plan effort has been made to document the wishes and requests of residents regarding their final affairs. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18,22,23,35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes complaints procedures required updating and revising to ensure that any persons wishing to make a complaint regarding the service provided could do so and complaints would be acted upon. There was a lack of staff training regarding awareness of abuse and the current financial arrangements of residents paying for staff escort duties was in need of further consideration to ensure protection of residents. EVIDENCE: The inspector sampled the complaints procedure, which was dated 2002. The procedure referred to the National Care Standards Commission and not the Commission for Social Care Inspection. The procedure was discussed with the deputy manager who told the inspector no complaints had been received by the home. A system for logging complaints was in evidence. The inspector also sampled the resident’s complaints procedure and it was noted that this needed revising to make it user friendly. A requirement has been made that both complaints procedures are revised and include all the necessary details for people to make a complaint if they wish to. As discussed Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 18 with the deputy manager it was agreed that one resident would understand a simple written format and for the remaining residents an improved pictorial complaints procedure would be developed. The inspector noted from the staff training files that only one staff member out of five had received training in the Safeguarding Adults in order to ensure that the home promotes the rights of residents to protection. The training record indicated that the four staff would be attending the necessary training on the 15.05.06. A requirement was made that all staff receive training to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The inspector sampled two residents cash tins and the records associated to the purchasing of goods. Improvements to the record keeping of resident’s finances were noted and the records sampled were well documented and accurate. One cash tin contained receipts related to the service users organised trip to the local theatre. The Deputy Manager advised that the residents pay for the staff to ‘escort’ them. There was no record of authorisation/consent of using the residents money and the homes Statement of Purpose and Service User Guide did not include details of this arrangement in order to ensure that residents, or their representatives had been informed or were aware of this arrangement. In addition it was noted that some residents were in receipt of the services of a hairdresser and chiropodist. These financial arrangements were also not documented in the residents care plans and must be included in order to safeguard the resident’s finances. A requirement has been made that the Registered Person investigates the matter of residents paying for staff to ‘escort’ them. The arrangement must be confirmed in writing by the resident and their representative and this record, including other additional services not covered in the fees must be available on the residents care plan. CSCI must be informed in writing of the outcome in order to ensure measures are in place to protect residents from abuse or being placed at risk of harm or abuse. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic throughout, several areas of the home had been newly decorated and all resident’s rooms were viewed as comfortable and individualised. EVIDENCE: The inspector had a tour of the premises, which throughout were observed as clean and hygienic. The home has been newly decorated and new carpets have been fitted to the main hallways and communal areas. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 20 All the bedrooms were well decorated, clean and hygienic. One resident showed the inspector their bedroom, which included their own furnishings, personal items and a new television. The resident told the inspector that they liked their room and was happy in the home. The communal areas of the lounge and dining room were clean. It was evident that the home managed the disposal of clinical waste in an appropriate way and the laundry area was also well ordered. The homes mobile hoist service maintenance certificate was current. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30,32,34,35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements were required in respect of staff training, induction and recruitment checks. A review and assessment of the care placement and support needs for one resident with Dementia is needed. EVIDENCE: On individual staff training files there remained shortfalls regarding the level of staff attendance of statutory training. This has been an ongoing shortfall of the home. The files sampled lacked evidence of statutory training for example moving and lifting, (one resident requires the use of the hoist and only two staff members have received training in moving and lifting) health and safety Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 22 (including risk assessments), Fire training, First Aid (including supporting people with epilepsy) and Basic Food Hygiene. The Deputy Manager explained that some staff training had been booked. On the previous inspection on 20.12.05 the requirement that all staff receive appropriate statutory training by 10.3.06 had not been met. The inspector requested a matrix of all staff training, which has been booked or undertaken to be sent to CSCI Eashing. The information has been received and details the dates for training within the next 3 months. A further immediate requirement has been made that the Registered Person must ensure that persons employed in the home receive training appropriate to the work they are to perform to ensure the safety and welfare of the residents and a staff training and development programme must be developed and implemented. The home is currently offering accommodation and care to a resident who has been diagnosed with advanced Dementia as previously documented in Standard 9. Whilst sampling the staff files it was evident that no staff had undertaken any training in understanding and awareness of Dementia and the associated issues for example communication, inclusion and meaningful activities. A requirement has been made that the Registered Person undertake an assessment with the resident, their Care Manager and any other representative to ensure that the residents needs are identified and met. The inspector was advised by the deputy manager that one staff member had been recruited by Welmede Housing Association in January 2006. Whilst sampling the staff members training file there was no evidence to indicate that the staff member had received a formal and structured induction. An immediate requirement was made that the Registered Person must ensure that all persons employed to work in the care home receive a structured induction. The inspector was unable to access staff recruitment files as the deputy manager did not have access to the files. The inspector was advised that the previous requirement that CRB checks for two staff members be obtained had not been met by 20.12.05. Welmede Housing Association had not obtained POVA First checks in the interim. A further immediate requirement was made that the Registered Person must ensure that all persons employed to work in the care home have adequate pre employment checks for example CRB disclosures or POVA First checks in order to protect residents from harm. The inspector sampled the staff rosters held in the home. Staff names and roles were unclear and contracted hours were not recorded on the rosters. The roster reflected the practice of one staff member being on duty for 56 hours per week. No records of sickness, annual leave or training days were available on the rota to reflect an accurate account of hours actually worked by staff. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 23 An immediate requirement was made that the Registered Persons must review the current roster to include the staff members role, contracted hours, hours actually worked including overtime in order to accurately reflect the staff deployment in the home for the welfare and benefit of the residents. It is recommended that the Responsible Individual attain a copy of the Department of Health, White Paper Valuing People for staff information and guidance. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are a high proportion of statutory requirements of serious concerns, which remain outstanding from previous inspections and the home is in need of a Registered Manager. EVIDENCE: Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 25 The pre inspection questionnaire informs CSCI that the previous registered manager retired in March 2006 and a new manager will be starting in ‘due course’. The home is currently being ‘overseen’ by a person who works at another Welmede Housing Association location. A high number of requirements have not been met from the previous inspections. CSCI have required in accordance with the Care Standards Act 2000 that a manager is appointed who has the day to day control of the care home and has the criteria of fitness detailed in the Care Homes Regulations 2001 (as amended). The homes insurance certificate, in respect of liability, displayed in the hallway had expired in March 2005. An immediate requirement was made that the Registered Person must ensure that the homes insurance certificate, in respect of liability, is up to date and available for inspection. On the previous inspection on 20.12.05 the requirement that a system be implemented to review the quality of care and seek service users, or their representatives views and opinions of the service provided had not been met by 10.3.06. A further immediate requirement was made that the Registered Person must establish and maintain a system for reviewing and improving the quality of care provided at the care home. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 26 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 2 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 1 33 1 34 1 35 1 36 1 CONDUCT AND MANAGEMENT Standard No Score 37 1 38 x 39 1 40 x 41 x 42 2 43 x 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Copse Lea Score 3 3 2 3 DS0000013610.V289057.R01.S.doc Version 5.1 Page 27 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 Regulation 8.1.& 9.1 Requirement The Registered Person must ensure that an updated certificate of registration is displayed within the home to reflect the current management arrangements. The Registered Person must ensure that the homes Statement of Purpose and Service User Guide are updated to include all details specified in the Care Homes Regulations (as amended) 2001 The Registered Person must produce a statement, which clearly explains the method of payment of fees. The Registered Persons must ensure that the home undertakes a review to identify the needs and develop an action plan to ensure that resident’s needs are met. The Registered Person must ensure that the homes menu be designed to accurately reflect choice, special diets and provide sufficient detail to determine that DS0000013610.V289057.R01.S.doc Timescale for action 14/05/06 2 YA1 4.(1) Sch 1 5.(1) 14/06/06 3 YA5 5(1)(b) 17(2) Sch4(8) 16 (2)(m) 04/05/06 4 YA13 04/05/06 5 YA17 Schedule 4 .13 14/06/06 Copse Lea Version 5.1 Page 28 6 YA20 7 YA23 8 YA23 9 YA32 10 YA35 11 YA34 the diet offered is nutritious. The Registered Person must ensure that all medication administered by staff to residents must be authorised by the GP including household remedies. Regulation The Registered Person shall 13 (6) make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 17.(2) The Registered Person must Schedule ensure that service users or their 4 representatives are made aware (9)(a)(b) of the purpose for which their money is used and consent obtained regarding service users paying for staff ‘escort’ and additional costs for example hairdresser and aroma therapist. The Registered Person must investigate this matter and take appropriate action of which CSCI must be informed. 18 (1c) (i) The Registered Person must ensure that all persons employed to work in the care home receive a structured induction. 18 (1)(a) The Registered Person must ensure that persons employed in the home receive training appropriate to the work they are to perform to ensure the safety and welfare of the residents. A staff training and development programme must be developed and implemented and a copy sent to CSCI Eashing. Not met 10/03/06 7,9,19 & The Registered Person must Sch 2 ensure that all persons employed (2)(a) to work in the care home have (b) adequate pre employment checks for example CRB 13.(2) DS0000013610.V289057.R01.S.doc 14/06/06 04/05/06 04/05/06 04/05/06 04/05/06 04/05/06 Copse Lea Version 5.1 Page 29 12 YA33 17.(2) & Sch 2 (6)(e) & 7 13 YA42 25 (2)(e) 14 YA39 24 (1) (a)(b) disclosures or POVA First checks in order to protect residents from harm. Not met 20/12/05 The Registered Person must 04/05/06 review the current roster to include the staff members role, contracted hours, hours actually worked including overtime in order to accurately reflect the staff deployment in the home for the welfare and benefit of the residents. The Registered Person must 04/05/06 ensure that the homes insurance certificate, in respect of liability, is up to date and available for inspection. The Registered Person must 04/05/06 establish and maintain a system for reviewing and improving the quality of care provided at the care home. Not met by 10.3.06. 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 YA35 Good Practice Recommendations It is recommended the home consider using behavioural monitoring charts (‘a.b.c.’ charts) which include the assessment of behaviour for example antecedent (what was happening prior to the behaviour) the behaviour being presented and the consequence of the behaviour including staff response and action taken. It is hoped this method of assessment would assist staff to understand more fully the links between the resident’s communication and behaviour. It is recommended that the Registered Person attain a copy of the Department of Health, White Paper Valuing People in order that the values, rights and staff training DS0000013610.V289057.R01.S.doc Version 5.1 Page 30 2. YA35 Copse Lea specific to supporting people with learning disabilities are considered. Copse Lea DS0000013610.V289057.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Surrey Area Office 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 DS0000013610.V289057.R01.S.doc Version 5.1 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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