Inspection on 02/08/05 for Copwood Respite Unit

This inspection was carried out on 2nd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copwood Respite Unit 29/10/07

Copwood Respite Unit 27/11/06

Copwood Respite Unit 04/01/06

Copwood Respite Unit 05/01/05

Copwood Respite Unit 21/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Copwood Respite Unit 15 Copgrove Road Holmewood Bradford BD4 0DJ Lead Inspector Carol Haj-Najafi Announced 2 August 2005 nd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Copwood Respite Unit Address 15 Copgrove Road Holmewood Bradford BD4 0DJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 684511 01274 684511 Bradford District NHS Care Trust Care Home Only 6 Category(ies) of Learning Disability (6) Dementia (6) Physical registration, with number Disability (6) Sensory Impairment (6) of places Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th January 2005 Brief Description of the Service: Copwood is a Bradford District Care Trust home situated in the Holmewood area of Bradford. The home is registered to provide respite care for up to 6 adults with learning disabilities. Copwood is attached to a day centre for adults with learning disabilities. It is a single storey building, hence all facilities are provided at ground floor level. The accommodation comprises of six single bedrooms. There are two bathrooms and one shower room, one bathroom has hoisting equipment. A ‘snoozelam’ room is also provided. The home has a domestic kitchen/ diner and a large lounge area. All laundering is undertaken on the premises. Copwood has an enclosed garden and a large car parking area is located at the front of the day centre. Local shops and bus routes are within easy access. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this announced inspection between 9.30am and 2.45pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. The inspector spoke to the manager and one staff member, looked around the home, and inspected records, which included, service user plans, admission assessments, daily records, staff training and recruitment records. A pre-inspection questionnaire was sent into the Commission before the inspection. Service users had left for day care when the inspector arrived. Therefore it was not possible to speak to service users or staff or observe interaction. Hence, a number of key standards were not inspected at this inspection. What the service does well: What has improved since the last inspection? What they could do better: Some service users that have transferred from a different service have not had the same opportunities to visit the home or have the same care planning process as other service users. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 6 Service users attend their usual day care services but they do not receive many opportunities to go out for recreational activities during their stay. There are quite a lot of areas that need decorating, and some of the furniture, curtains and carpets are old and shabby. The garden is overgrown and clinical waste bins are stored near the door; this poses a risk to service users. It is quite difficult to shower or bath some service users because the assisted bath can only be accessed from one side and service users have to step over a ridge to get to the shower. The problems with the building were highlighted at the last inspection. Requirements and recommendations identified at this inspection can be found at the end of this report. 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. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 The home’s admission process is good but the same process must also be applied for service users transferring from other Bradford Care Trust services. Service users are issued with relevant information when they start using the respite service. The new statement of purpose is good, however, some additional information must be added to ensure the reader is able to receive sufficient detail about the home. EVIDENCE: Service users are referred to Copwood through an allocation meeting. If managers and social workers think the service user is suitable, a referral is made to the home. The manager will then contact the service user, carer and social worker. Service users are given opportunities to make several visits to the home. One service user who had recently started using the service had a gradual introduction, and an assessment and service user plan had been written up as part of the introduction period. Information had also been sought from the main carer. Three service users who recently started using the respite service had social work assessments in their files. The manager said that core assessments are obtained from social workers and/or health care professionals as part of the referral process. Two service users had transferred from another Bradford District Care Trust respite service, and although social work assessments had been completed, the home’s assessment and visiting arrangements were not as thorough as the usual admission process. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 9 Service users are issued with respite contracts. The manager has been contacting all existing service users and their carers to issue contracts. This process is nearly complete. The home’s statement of purpose has just been produced; it provides good information about the admission process, health care arrangements, staff training and keyworker roles. There is no information about the size of rooms, which must be included in a statement of purpose, and it does not clearly state that the respite unit does not provide a service on weekdays between 10.00am- 3.00pm. It would also benefit from more information about what service users can do during their respite stays. The manager is planning to include additional information about individual staff members although this is only in the early stages. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 New service user plans and risk assessments have been introduced; these are very good, and clearly identify how a person’s needs should be met. A system for reviewing the plans must now be agreed to make sure the information is updated. Service users transferring from other services must also have a service user plan to ensure their needs are met. EVIDENCE: A new format for service user plans has been introduced during the past twelve months. Nearly all plans have now been transferred to the new format. The manager and keyworkers have visited service users and their carers to discuss the service user plans, and obtain information about their care needs. Care records for four service users were looked at. Three plans were in the new format. These service user plans were very specific, and clearly identified the support required to meet the person’s needs. Each service user plan was very individual and written using a person centred approach. Risk assessments are completed and action points are well defined. Two service users that had transferred from another service did not have a plan. A system for reviewing individual plans has not yet been introduced. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 & 17 Service users do not have many opportunities to go out into the community. The quality of meals has improved since the last inspection. EVIDENCE: The last inspection identified that opportunities to access the local community were very limited. Since the inspection an additional member of staff has been allocated to the home. However, the manager and staff said that service users do still not have sufficient opportunities to go out. Daily records confirmed this. The last inspection identified that catering arrangements must be reviewed. Menu plans have been introduced, and service users likes and dislikes are being recorded. The manager is responsible for purchasing provisions, and bases food orders on the new menus. Any alternative meals are recorded. The manager said although the changes have only recently been introduced the quality and nutritional content of meals has improved. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Healthcare needs are appropriately met. EVIDENCE: Copwood does not take overall responsibility for health care needs but they will support service users and long term carers if required. Bradford’s learning disabilities services complete health care surveillance assessments, and coordinate health care needs. Most service users have a copy of the assessment in their file. Any health care needs or appointments that are arranged during respite stays are recorded, and the relevant information is passed on to the main carers. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Complaints are properly investigated but the procedure needs changing to make sure complainants know they can also contact the CSCI. EVIDENCE: The home has received two complaints within the last twelve months. These have been properly investigated and action has been taken to resolve any issues. A letter that is sent to the complainant gives details of two organisations that can be contacted if they are unhappy with the outcome. Details of the Commission for Social Care Inspection must be included. This has previously been brought to the attention of Bradford District Care Trust. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 & 30 The home is kept tidy but it looks shabby, and much of the furniture and furnishing are old and damaged. The enclosed garden is not properly maintained, therefore service users do not benefit from this facility. The home struggles to meet some service users personal care needs because bathing and showering facilities are not suitable. EVIDENCE: The inspector visited all areas of the home. It was tidy and domestically well organised. Moving and handling equipment is provided and some environmental equipment has been provided for individual service users. As a respite unit, personalisation of rooms is limited. The last inspection identified that the organisation must produce a programme for decoration and renewal of furniture and equipment, and provide storage facilities in the bathrooms. These requirements have not been met. This inspection again highlighted areas of work. Wallpaper in all bedrooms was damaged, paintwork in corridors and external parts of the building was peeling or damaged or dirty. Furniture was old and damaged. The lounge carpet is very badly marked. Four kitchen cupboards did not have any doors on them. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 15 Ceiling and wall tiles were damaged and stained. One bathroom has an assisted bath, however, this can only be accessed from one side, which makes it very difficult to support service users, especially those who use the overhead hoist. The shower from the bath only supplies cold water, which makes hair washing and rinsing very difficult. A separate shower room is also provided but a step up into the shower makes it difficult for a lot of service users to access. An industrial washing machine, with a sluicing facility and dryer are provided. Procedures are in place for control of infection. Service users can access an enclosed garden but this is overgrown and some large thistles were growing. There were two garden chairs but no other furniture. Clinical waste bins are stored in the garden; measures have not been taken to prevent service users from gaining access to these. The manager said the home has met the requirements from the last environmental health and fire service visits. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 Staff receive regular training which equips them with skills and knowledge to meet the needs of service users. Staff records that must be kept at the home are not available for existing staff; therefore it is not possible to establish if the recruitment process has been thorough. EVIDENCE: Staff have attended training courses which cover health and safety areas and good care practice; these include, LDAF (learning disability award framework), British sign language, safe holding, breakaway, basic food hygiene, report writing, valuing people, autism/ communication and person centred planning; three care staff have completed NVQ level 2 and one has nearly completed. A new employee confirmed that they had spent time learning routines and getting to know service users as part of their induction programme. Training records are maintained to enable the manager to monitor training attendance and identify training needs. Recruitment records for existing staff are held at Bradford District Care Trust’s central office and are not available in the home. A requirement at the last inspection identified that these records should be kept in the home. Standard 33 which relates to sufficient staffing numbers was checked to establish that the requirement from the last inspection had been met. Since the inspection an additional 28 hours have been allocated to the home. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40, 41 & 42 The home has systems in place to seek the views of service users. Records are detailed and provide good information about events that have taken place. The health and safety of service users and staff are protected but evidence that an electrical wiring check has been carried out must be forwarded to the CSCI. EVIDENCE: Three service user meetings have been held during the last six months. An independent liaison worker attended two of the meetings and staff attended the other. Minutes from the meetings were looked at. Service users that are able to air their views have been assisted by staff to complete a survey about the quality of the respite. Daily records are detailed, and these provide an overall picture of what a service user does during their respite stay. Accident and incident reports are also completed in detail. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 18 The pre inspection questionnaire confirmed that policies and procedures are available and regular maintenance and health and safety checks are completed at the home. An electrical wiring certificate was not available; therefore it is not possible to establish that the home’s electrics are safe. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 2 2 3 2 Standard No 11 12 13 14 15 16 17 x x 1 x x x 3 Standard No 31 32 33 34 35 36 Score x x x 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Copwood Respite Unit Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 3 3 2 x 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 4 Requirement The homes statement of purpose must include information about room sizes, weekday arrangements and recreational opportunities. Service users transferring from other Bradford Distict Care Trust services must receive the same assessment, introductory and care planning processes as other service users A system for reviewing service user plans must be introduced. The registered provider must ensure service users have opportunities to access the community. The registered provider must ensure details of the CSCI are included in the complaints procedure. A programme of renewal and redecoration must be produced; works identified in the main body of the report must be included. (Timescale of 31st October 2004 & 31st March 2005 not met) The registered person must provide suitable storage facilities for equipment stored in the 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Timescale for action 30th September 2005 30th September 2005 2. YA3 14 3. 4. YA6 YA13 15 16 30th September 2005 30th September 2005 31st October 2005 31st Decemebr 2005 5. YA22 22 6. YA24 23 7. YA27 23 31st December 2005 Page 21 Copwood Respite Unit Version 1.30 8. YA27 23 9. YA30 16 10. YA34 17 11. YA42 23 bathrooms. (Timescale of 30th November 2004 and 31st March not met) The registered provider must ensure the home has suitable bathing/ showering facilities to meet the needs of service users. The registered provider must remove the clinical waste bins from the garden and ensure a system is introduced that ensures clinical waste is disposed of safely. The registered provider must ensure staff records, which are required under regulation, are available in the home. (Timescale of 31st March 2005 not met). The registered provider must provide evidence that an electrical wiring check has been carried out. 31st October 2005 30th September 2005 31st October 2005 30th September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations Suitable garden furniture should be provided. Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Copwood Respite Unit 20050802 Copwood AN Stage 4 S46758 V185322 J52.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!