CARE HOME ADULTS 18-65
Copse Lea Copse Lea Tringham Close Ottershaw Surrey KT16 0NF Lead Inspector
Christine Bowman Key Unannounced Inspection 6th March 2007 11:00 Copse Lea DS0000013610.V313175.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.V313175.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.V313175.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) Welmede Housing Association Ltd To Be Confirmed 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.V313175.R01.S.doc Version 5.2 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 4th May 2006 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 acting manager of Copse Lea. Fees are £1,039 per week. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection process. The visit took place over six hours commencing at 11.00 am and ending at 17.00 pm and was undertaken by Ms Christine Bowman, regulation inspector. One senior care worker and three residents were at home when the inspector arrived and a further two care workers and the remaining three residents returned to the home throughout the day. A tour of the shared accommodation was undertaken and three residents invited the inspector to view their bedrooms. The acting manager was on annual leave so a Wellmede service manager was called for access to be gained to the staff personnel files, two of which were inspected. The training records of the staff members sampled were also viewed. Three care workers were interviewed, a domestic assistant in the laundry was spoken with, and three residents commented about their lifestyles and how happy they were to be living at the home. Five residents completed comment cards with support from the staff. Three resident’s files containing their care plans, risk assessments and health related information were viewed. The Statement of Purpose, the Service User Guide and policies and procedures were sampled. Resident’s medication, meals taken and financial records, the minutes of staff and resident’s meetings, and health and safety checks were also inspected. All the residents were gathering in the dining room when the inspector left. They were happily awaiting their home-cooked dinner prepared by one of their care workers. The meal of lamb casserole, mashed potatoes carrots and courgettes looked and smelt delicious. The inspector would like to thank all those who assisted with the inspection process and contributed to the report and particularly the residents and staff who spent time completing the service user surveys. What the service does well:
Residents are encouraged to follow their interests and there was evidence of choice in leisure activities and the opportunity of taking an annual holiday. ‘I’m very happy with the way things are and I like it here,’ was a comment made by one resident. Another resident had a special interest in aeroplanes and had acquired an interesting collection, which were displayed in his bedroom. ‘I like to attend air shows,’ he stated, ‘and I like listening to music.’ He had a comprehensive collection of compact discs and tapes and equipment in his room on which to play them. The home was comfortable, homely, clean and hygienic and fulfilled the needs of the residents. The sitting room was comfortably furnished with matching curtains, framed pictures and a variety of houseplants. There was a television
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 6 and music system for the entertainment of the residents and magazines and newspapers in the magazine rack and on the occasional table. In the corridor, just outside the sitting room, was a notice board with information for the residents on holidays, day trips and variety of social activities including bingo and whist, discos and tea dances. The residents benefited from being cared for by a committed and stable staff team who knew and understood them well. ‘They always have time for me,’ was a comment from a resident in reply to the question, do the staff listen and act on what you say? All the residents, who completed comment cards, replied, ‘always’, to this question. Another resident stated, ‘they are very nice people.’ What has improved since the last inspection?
Since the previous site visit an acting manager, with previous experience of being the registered manager of another home, had been appointed. The acting manager was in the process of applying to be considered as the registered manager for this home. Some of the staff were enthusiastic about the improvements she had already made and were eager to show how new ideas had been incorporated into the running of the home. Both the Service User Guide and the Statement of Purpose had been reviewed and were presented attractively. The Service User Guide was in a format, which was accessible to the residents and prospective residents, and contained photographs and symbols to enable a clear understanding of what the home had to offer. A detailed care plan, the involvement of appropriate specialists, the obtaining of a specially adapted vehicle and the training of staff in dementia awareness had been instigated to fulfil the special needs of a resident as required from the previous site visit. Residents meetings had been set up and residents could choose to have an audio recording of these or a printed version with photographs to remind them of topics discussed. The residents were much more involved in menu planning and colourful pictures had been used to enable choices to be made. All meals taken had been recorded so it was easy to see that the diet was balanced and nutritious to promote the health of the residents. Authorisation had been sought from General Practitioners for the administration of homely remedies in order to protect the residents. Criminal Record Bureau (CRB) checks had been carried out with respect to the staff sampled and a list of all the CRB numbers and dates of receipt was kept to verify this for the protection of the residents. Staff training in the protection of vulnerable adults had been undertaken to protect the residents from harm and a staff training and development programme had been developed and
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 7 implemented to equip the staff for their caring duties. A staff member stated that the new acting manager had arranged supervision sessions to support the staff, but no one had been supplied with a copy to verify this. A staff member stated that there was no charge to the residents to be accompanied by staff when escorted on trips, but there no statement was seen in resident’s files with respect to the payment for any extra services to verify this. An insurance certificate on display in the home was in date and confirmed protection for the residents and staff. What they could do better:
The Service User Guide did not contain the information with respect to the payment of fees as required in recent legislation to inform the residents and their representatives. Six monthly review dates were recorded but no new care plans had been developed and there were no records of review meetings held on two of the three files inspected. However, a detailed person-centred care plan had been drawn up for a resident, whose needs had changed considerably and a review meeting had been held involving various specialists. The acting manager confirmed in documentation sent to the Commission for Social Care Inspection that all residents would be reviewed in the same way. A local medication policy and procedure to guide the staff and instruct them of action to be taken with respect to drug errors and other emergencies could not be found on the day of the site visit. The local authority policy and procedure for the protection of vulnerable adults was not in its folder and the home did not have a local policy based on this to instruct the staff on the action to take should a safeguarding situation arise in order to protect the residents from harm. 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 staff personnel files were not bound or ordered in any way, which made finding the necessary documentation time-consuming. From a contents list also found in the cabinet, it was clear the acting manager was already in the process of improving the system. Documentary evidence of a structured induction based on the common induction standards was not seen in staff personnel files, but there had been no newly recruited staff to which this would apply. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 8 The quality assurance system needs to be expanded and the service needs to show how feedback from residents affects the development of the service. 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.V313175.R01.S.doc Version 5.2 Page 9 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.V313175.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 1&2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information available to residents and potential residents to inform them about the home had improved and was more accessible to them, but there were some omissions with respect to statutory information required with respect to the payment of fees. An assessment policy was in place to ensure the home only admitted residents whose needs could be catered for. EVIDENCE: The Statement of Purpose and the Service User Guide had been reviewed and were well presented and informative. The Service user Guide was in a format, which was accessible to the residents and prospective residents, and contained photographs and symbols to enable a clear understanding of what the home had to offer. In the light of new legislation the Service User Guide must include a description of the standard services offered by the care home to the clients and the fee payable for this. Also included must be the arrangements for charging and paying for any services additional to the standard service. A statement must be included to explain how these arrangements would be affected if all or part of the fee was provided by a person other than the client. Standard 5 was not inspected but a requirement had been made at the previous site visit that a statement, clearly explaining the method of payment of fees, should be produced. There was no evidence that this information had
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 11 been received at the CSCI local office and the staff on duty were unable to help so this unmet requirement will be given a further time limit to be completed. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in the assessment and review process had resulted in a care plan, which better reflected the needs of a resident to ensure their changing needs were met. The improved process will also benefit other residents. Residents are able to make decisions about their lives and take risks as part of an independent lifestyle with support. EVIDENCE: Resident’s care plans were sampled and it was clear that their needs and personal goals were reflected and that actions were in place to fulfil those needs. Six monthly review dates were recorded but no new care plans had been developed and there were no records of review meetings held. However, a detailed person-centred care plan had been drawn up for a resident, whose needs had changed considerably and a review meeting had been held involving various specialists. A document was viewed confirming that a specially adapted vehicle had been ordered, to enable this resident to access the community and be included in trips out, and a delivery date was pending. Staff training in dementia awareness had also been instigated to fulfil the special needs of a
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 13 resident as required from the previous site visit. The acting manager wrote on pre-inspection documentation that all residents would be reviewed in the same way. Information with respect to advocacy services was available on the resident’s notice board and this service had been requested for one resident. A key worker system was in place to support the residents and the services of a speech therapist had been enlisted to support the communication needs of one resident. Risk assessments had been completed with respect to independent living and mobility to ensure the residents were safe both in the home and accessing the community. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Many opportunities are provided for the clients to engage in peer and culturally appropriate activities in the community. Relationships are promoted, rights and responsibilities recognised and the clients enjoy a wholesome balanced diet. EVIDENCE: ‘I decide to go to work because I like working’, was a comment from one resident, who goes to work in recycling for the council three days every week. Some residents attended courses at Adult Education Centres and chosen activities included woodwork, art and craft, cookery and ‘The World we live in’. Some residents enjoy accompanying staff on shopping trips for the weekly groceries, a staff member stated. ‘I like to clean my room,’ another resident stated. All the residents confirmed in their comment cards they could do what they wanted to do daytimes, evenings and weekends. One resident commented, ‘I like going out at the weekends, not always though.’ Residents did not have their own timetables and three, including a resident with mobility needs, were at home all day when the site visit took place, watching
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 15 the television in the sitting room or in their bedrooms. Some residents were able to safely walk to the local shops unaccompanied, a staff member stated. Planned improvements by the new acting manager included the further development of all staff on enhancing choice, resident participation and accessing local community facilities and she stated that, ‘this is currently being discussed through meetings and supervision and action plans are being set’. A member of staff stated that, ‘ Wellmede, the provider organisation, arrange a monthly meeting at a hall in Chertsey, where residents can socialise with residents from other homes. They have cakes and soft drinks and enjoy singing songs. Usually four of the residents choose to go’. One resident had visits from relatives on special days such as Mother’s Day and Christmas and was sometimes taken out. Another resident liked to attend church and was able to access the local church alone as it was just up the road. Relationships were supported and care plans showed that two residents who had developed feelings for each other had opportunities to be alone together. One resident had a special interest in aeroplanes and had acquired an interesting collection, which were displayed in his bedroom. ‘I like to attend air shows,’ he stated, ‘and I like listening to music.’ He had a comprehensive collection of compact discs and tapes and equipment in his room to play them. The three resident’s bedrooms viewed were personalised and contained large televisions, which they were very pleased with. The organisation had an activities organiser and there was information for the residents about holidays and social clubs on the resident’s notice board. One of the residents takes charge of the notice board, putting up new notices and taking down old ones. A member of staff stated that residents had been on holidays to Spain and Euro Disney and on day trips to Chessington World of Adventure and the coast. Since the previous inspection, a resident with mobility needs had been included in trips to the theatre, cinema and shopping by using a wheelchair accessible taxi and the staff were undergoing assessments for driving the specially adapted vehicle, which had been ordered to enable them to join in. The local community also offered parks, pubs and a swimming pool, which some residents enjoyed. Improvements had been made with respect to menu planning. A weekly meeting had been set up and colourful pictures of food were used to enable residents to make choices with support from the staff to ensure the meals were well balanced and nutritious. The weekly menu was displayed in the dining room to remind the residents of the meals they had planned. Residents confirmed in their comment cards that they always enjoyed the meals. One resident’s care plan showed that they did not like the new way of choosing the menu and preferred it when the staff chose. She had been asked if she would tell her key worker all her likes and dislikes with respect to food to ensure that
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 16 some of her favourite meals were included and she didn’t need to attend the meeting. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents confirmed they received support in the way they preferred and required and their physical and emotional needs were met. Planned improvements were in place in respect of health action planning. However, essential guidance was not in place to instruct the staff in the event of medical emergencies and to ensure correct procedures were followed. EVIDENCE: The new person-centred care planning was clear in the recording of the way a resident preferred their support to be given. From observations of the staff working with the residents, it was clear their preferences were understood and acted upon. Resident’s files included evidence of the involvement of health professional such as speech therapists, General Practitioners and specialist support for dementia. The resident’s health needs were being met as evidenced in their files but the acting manager stated she will be reassessing and evaluating the system with involvement from the whole team and health action planning would be introduced. Health action planning training had been accessed by some staff and had been booked for others. 100 of residents, who completed comment cards, confirmed they received the medical support they needed.
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 18 A local medication policy and procedure to guide the staff and instruct them of action to be taken with respect to drug errors and other emergencies could not be found on the day of the site visit. There was no evidence of accredited training in the administration of medication, but a staff member confirmed they had received this training. Medication was appropriately stored and a dosage system supplied by a local pharmacy was in place. The medication administration record had been completed and a system was in place to receive medication and to return unused medication to the pharmacy. The pharmacist had signed this. General Practitioners had authorised the taking of homely remedies. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 19 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 the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made to the complaints procedure making it more user-friendly and residents confirmed they knew how to complain and that they were listened to. Staff ‘safeguarding’ training offered more protection to residents from potential abuse but the home did not have it’s own safeguarding policy which reflected the local authority multi-agency procedure to instruct the staff and protect the residents. EVIDENCE: Residents meetings had been introduced and the minutes showed that residents were encouraged to make their views known. Actions from the minutes of the meetings confirmed that residents were listened to and their views were acted upon. A revised complaints procedure had been produced which was colourful and contained symbols and large print, making it more accessible to the residents. A copy was on view on the resident’s notice board and it was also contained in The Service User Guide, which all residents held a copy of in their bedrooms. Residents confirmed in their comment cards, they knew who to speak to if they were not happy and that they also knew how to make a complaint. One resident commented, ‘I speak to the staff if I am not happy,’ and if they wished to complain, ‘I tell the staff when I go to the Wellmede meetings.’ A system of logging complaints had been seen at the previous site visit but could not be located for inspection. Since the previous inspection the staff had undertaken training in the protection of vulnerable adults and certificates were on file to reflect this. The local authority policy and procedure was not in its folder and the home did not
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 20 have a local policy based on this to instruct the staff on the action to take should a safeguarding situation arise. The finances of two residents were sampled. No residents maintained their own benefit books or financial affairs, but five residents were able to sign for their own finances. Wellmede had applied for attorney with the Public Guardianship office for one resident and a court date had been set. All the residents had their personal allowance to dispose of as they wished and records and receipts were kept. All the residents had individual savings accounts. No additional charges were listed and a staff member confirmed that there was no charge to residents for staff escorts on trips out, which had been noted at the previous site visit. The manager stated in the preinspection documentation that the management of resident’s money, valuables and financial affairs was in the process of re-assessment. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 21 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 the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was comfortable, homely, clean and hygienic and fulfilled the needs of the residents. The practise of wedging open some fire doors for the convenience of the residents and the staff was not safe. EVIDENCE: The ground floor of the home was suitably adapted with ramps for wheelchair users and the downstairs bathroom had been fitted with an assisted bath, a hoist and grab rails. Minor repairs were required to the bath and a cracked glass panel in the front door, but they posed no risk to the residents. They had been made safe and repairs were in hand. The sitting room was comfortably furnished with matching curtains, framed pictures and a variety of houseplants. There was a television and music system for the entertainment of the residents and magazines and newspapers in the magazine rack and on the occasional table. Two residents were watching a show on the television when the inspector toured the premises. In the corridor, just outside the sitting room, was a notice board with information for the residents on holidays, day trips and variety of social activities including bingo and whist, discos and tea
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 22 dances. The resident’s complaints procedure was also posted there along with details of General Practitioners. The dining room, which was also well furnished and homely, opened out into a well-equipped kitchen. There were two French windows also leading from the dining room onto a terrace in the garden, which, a member of staff stated, was used for eating outside in the summer months. One of the residents enjoys working in the garden, a member of staff stated. An enlarged framed photograph of all the smiling residents was hanging on the dining room wall and there was a colourful menu showing pictures of the prepared meals. Two residents, whose bedrooms were located on the ground floor, had wedges to keep their doors open. The staff were asked to remove them because they were fire doors. If the residents and staff wish to continue with this practise, a suitable system must be installed to ensure the doors would automatically close if the fire alarm sounded. A recent visit had been made by the fire officer and the recommendations made were in the process of being dealt with, as stated in the pre-inspection data. The home was clean and fresh and good facilities were in place to promote safe hygiene practices. All the residents, who completed comment cards, also confirmed that they thought the home was always clean and fresh and one resident commented, ‘Yes it is very fresh and clean, the staff are always keeping things clean and I like to clean my own room.’ Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 had been made with respect to the mandatory and specialist training of the staff to meet the needs of the residents and essential safety checks had been carried out to confirm their suitability for care work and to protect the clients. However, the staff personnel files were not in good order and recruitment and induction processes unclear leading to uncertainty about the initial preparation of the care staff for personal care duties. EVIDENCE: Two staff personnel files were inspected. There had been no new recruits since the previous site visit so it was not possible to ascertain if there had been improvements in the recruitment procedure. The files contained the required information, but the application form was in need of review, as it did not require a full employment history. The service manager, who brought the key to the cabinet containing the staff files explained the new application form was available on-line and did require this information. It was difficult to be clear about the recruitment of the staff because some had been bank staff prior to working at the home on a permanent basis. However, a list of Criminal Record Bureau checks numbers was held on file with the dates of receipt and a statement of no outcomes. This confirmed that the staff sampled had not taken up permanent posts in this home until the checks had been received. Personnel
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 24 files contained interview notes, equal opportunities forms, two references, health declaration and a photograph. The files were not bound or ordered in any way, which made finding the necessary documentation time-consuming. From a contents list also found in the cabinet, it was clear the acting manager was already in the process of improving the system. Staff individual training and development logs had been set up and certificates confirmed that mandatory training had been accessed along with Dementia Care, Equality and Diversity, Conflict Resolution, Risk Management and MRSA. There was no evidence of a structured induction in the personnel files of the staff selected, but a staff member described their induction. They stated that a good support system was in place and that the home had a process, which was followed. The Copse Lea Induction Pack contained staff and induction handbooks and a schedule to follow including essential reading. The service manager confirmed that the common induction standards would be used in the future and evidence of a structured induction would be on file for all newly recruited staff. Standard 33 was not fully inspected, but a requirement was made at the previous site visit with respect to the staff roster. This was that the current roster should be reviewed to include the staff member’s role, contracted hours, hours actually worked including overtime in order to accurately reflect the staff deployment in the home for the welfare and benefit to the residents. Some improvement had been made to the system in that the senior staff for each shift were indicated in colour but the other information was not recorded on the sheet currently in use. However, a sample copy of a four-week rota sent to the CSCI local office contained the required information. In response to the question, ‘Do you receive the care and support you need?’ all the residents confirmed they always did and one resident added with reference to the staff, ‘they are very nice people.’ Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced acting manager has made a number of improvements to the running of the home, which benefits the residents. Resident’s meetings provide an opportunity for the residents to participate in the running of the home and to contribute to decision-making, but this process needs to be formalised and expanded in developmental planning. Policies and procedures in place with respect to health and safety and the mandatory training of the staff promote the welfare of residents and protect them from harm. EVIDENCE: An experienced acting manager had been appointed; who had completed the Registered Manager’s Award and had been the registered manager of a home previously. It was clear from the improvements, which had already been instigated, and those in process, that the manager possessed the leadership qualities and enthusiasm to ensure the home was run in the best interests of the residents. There remained a number of areas, which require improvement,
Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 26 and the home had not always complied with legal requirements in a timely fashion in the past. A quality assurance questionnaire was viewed on a resident’s file, completed by a relative and residents were regularly consulted in meetings, where they were encouraged to participate in decision making with respect to the day-today running of the home. Advocacy had been requested for a resident, who was unable to communicate verbally, to support them to give their views. However, there was no formal system in place for evaluating the quality of the service provided and including the resident’s views in the continuous improvement of the home. The acting manager stated she was currently liaising with the provider organisation, Welmede in relation to the annual development plan for quality assurance. The home had policies and procedures in place for health and safety and also fire safety. The acting manager stated that relevant policies and procedures would be made more accessible to the residents. All the necessary safety checks had been undertaken and recorded and copies of safety certificates were held on file. Staff had received training in Health and Safety, Control of Substances Hazardous to Health, Moving and Handling, First Aid, Fire Safety, Food Hygiene and the Protection of Vulnerable Adults Procedures. There was an ongoing programme of maintenance and repair. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 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 2 X 3 X 2 X X 3 X Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 28 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 YA1 Regulation 5(1)(a)(2)5(B) Requirement Timescale for action 01/04/07 2. YA5 3. YA20 4. YA23 5. YA24 The Service User Guide must include the details of the total fee payable for standard care and additional services must also be included to inform the clients, prospective clients and their representatives. 5(1)(b)17(2) A statement must be Sch4(8) produced, which clearly explains the method of payment of fees. This requirement had not been met and an extended timescale has been set for the second time. 13(2) Advice should be taken from a pharmacist on the writing of a medication policy and procedure to inform the staff and protect the residents. 13(6) A local policy and procedure, which reflects the local authority multi-agency adult protection procedures, must be developed to inform the staff and protect the clients. 12(10(a)13(4)(a) When fire doors are kept open for the convenience of
DS0000013610.V313175.R01.S.doc 01/04/07 01/04/07 01/04/07 01/05/07 Copse Lea Version 5.2 Page 29 6. YA32 18 (1c) (i) 17(2)6(g) Schedule 2(6) 7. YA34 8. YA39 24 (1) (a)(b) the residents and the staff a safe system must be in place to ensure they close in the event of a fire alarm. Records of a structured induction must be kept on the personnel files of all newly recruited staff. A full employment history with an explanation of any gaps in employment must be obtained in respect of potential new care staff prior to employment. A system must be established and maintained of reviewing and improving the quality of care provided at the care home. This requirement had not been met and an extended timescale had been set. 01/05/07 01/04/07 01/05/07 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 YA34 Good Practice Recommendations The staff personnel files should be bound and in good order so the recruitment process can be accurately followed and the information with respect to the commencement of employment at the home separated from the original North Surrey Primary Care Trust documentation. Copse Lea DS0000013610.V313175.R01.S.doc Version 5.2 Page 30 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
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