Inspection on 04/01/06 for Copwood Respite Unit

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 5 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 02/08/05

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 Unannounced Inspection 4th January 2006 2:30pm Copwood Respite Unit DS0000046758.V273942.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 Copwood Respite Unit DS0000046758.V273942.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 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. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Copwood Respite Unit Address 15 Copgrove Road Holmewood Bradford BD4 0DJ 01274 684511 01274 684511 julie.hillan@bckt.nhs.uk 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) Bradford District NHS Care Trust Mrs Julie Hillam Care Home 6 Category(ies) of Dementia (6), Learning disability (6), Physical registration, with number disability (6), Sensory impairment (6) of places Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 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 snoozelum 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 DS0000046758.V273942.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection between 2.30pm and 6.40pm. The purpose of the inspection was to make sure the home was operating and being managed to a satisfactory standard. I spoke to two residents, two staff and the registered manager. Service users staying at the home have very complex needs, and discussions with the majority of service users are limited. The inspector observed interaction between service users and staff. Records were inspected including care plans, assessments, maintenance records and staff records. Feedback was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? Additional information has been included in the statement of purpose. There is now information about recreational activities and times when the respite unit is closed. A system for reviewing care plans has been devised; this had just started so very few plans had been reviewed. New carpets in three rooms and cabinets in the bedrooms and bathrooms have been purchased. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 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 the following standard(s): 1 The statement of purpose is good. EVIDENCE: The last inspection identified that some extra information should be included in the statement of purpose. This work has been completed and now the statement of purpose includes more information about recreational opportunities and states specific times when the unit is closed. The last inspection also identified that service users who transfer from other Bradford District Care Trust respite services should receive the same quality admission process that other service users receive. The manager said that since the last inspection no service users have transferred over but some are in the process of doing so. The manager said visits and assessments would take place before they start using the respite service. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 9 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 Service user plans and risk assessments are very good although some must be updated. Service users have opportunities to be involved in decision-making processes but this is limited because service users do not live at the home. EVIDENCE: Care records for three service users were looked at. Two plans were in the new care plan format that has been introduced. These service user plans were very specific, and clearly identified the support required to meet the person’s needs. One care plan had very good information about administering medication, communication and eating. The other care plan had information about moving and handling techniques. Each service user plan was very individual and written using a person centred approach. Risk assessments are completed and action points are well defined. A new system for reviewing service user plans has been introduced but most plans have not yet been reviewed. The manager said they would be reviewed at least every six months but more frequently where appropriate. One service Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 10 user plan had been written in November 2005 but two of the plans had not been updated within the last twelve months. Decision making processes for services uses staying at Copwood are limited because they are only staying for respite care for short periods of time, therefore they can not be offered the same choices as people who live somewhere long term. Regular service user meetings are held. A representative from a local advocacy organisation attends meetings approximately every two months. Staff also arrange meetings. Discussions usually revolve around what service users want to do during their stay. Staff gave examples of how individual choice is promoted, these included choice of meals, activities and times for going to bed. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15 & 16 The provision of recreational activities is generally satisfactory but there are busy periods when this is restricted. Communication with families is good. Staff interact well with service users. EVIDENCE: Although service users have very limited verbal communication therefore it is difficult to discuss the quality of the service with those who use it, two service users did say they liked staying at the unit and were happy. The inspector sat with service users and staff for the evening meal. The meal was well organised, relaxed and enjoyable. The unit has recently raised some money and purchased two portable televisions and two CD players. This equipment has provided service users with the option of watching TV or listening to music in their rooms. The last inspection identified that opportunities for service users to go out to the community during respite stays were limited. Since the inspection there has been an increase in community activity and several outings have been Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 12 arranged, although it was acknowledged due to a limited number of drivers, outings during recent weeks have been very infrequent. All service users continue to attend their usual day service during the week. Therefore they only tend to have time for activities on an evening and a weekend. Staff spoke about different group and one to one activities. Staff said service users often enjoy relaxing evenings watching television and general chatting when they have been out at day care. The manager and staff acknowledged that sometimes the unit is very busy and it is difficult to provide individual activities. The manager and staff regularly liaise with service users’ families. Carers have been actively involved in devising care plans and risk assessments. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 13 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 & 20 Good systems are in place to ensure service users are supported in the way they prefer. Medication systems are satisfactory. EVIDENCE: Service user plans contain good information about how service users should be supported, this includes transfer techniques. One service user plan had photographs that identified how a service user should be positioned. Staff and the manager spoke of maintaining consistency for service users during respite stays. This includes continuing with routines that are carried out at home where appropriate. Staff discussed how they promoted privacy, dignity and choice within the home. Service users bring medication from home in containers that have been issued by the pharmacy. Stock checks are completed when medication is brought in, after administration, and when being returned. Medication records, booking in of medication and administration of medication were observed during the inspection. All practices were carried out correctly. Some previous errors had been recorded and dealt with by the manager. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 14 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 Complaints are properly investigated but the procedure needs changing to make sure complainants know they can also contact the CSCI. Good systems are in place to make sure service users are protected from abuse. EVIDENCE: The home has received one formal complaint within the last twelve months. The manager also records concerns that are raised with the home. Complaints and complaints have been well recorded and details of investigations and action that has been taken to resolve issues are included. A letter that is sent to the complainant gives details of two organisations that can be contacted if they are unhappy with the outcome; the Commission for Social Care Inspection is not included. The care homes regulations clearly state that they must be. This has previously been brought to the attention of Bradford District Care Trust. The manager and staff have attended adult protection training and were familiar with procedures and when to report any allegations of abuse. Service users bring spending money for activities and outings. Any money spent is recorded and receipted, and money is returned to the service user when they go home. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 15 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, 27 & 28 Service users are currently using a service that is in a poor state of repair. The home is kept clean and tidy but it looks shabby, and much of the furniture and furnishings are old and damaged. Bradford District Care Trust have failed to address requirements that have been highlighted at the last two inspections, therefore, they are failing in their duty to provide premises that are kept in a good state of repair and are reasonably decorated. EVIDENCE: The last two inspections have identified that the organisation must produce a programme for decoration and renewal of furniture and equipment. This requirement has not been met. A programme is required because there are many areas in the home that are below the minimum standard. The last inspection highlighted areas of work that needed attention. Very little progress has been made since. This is unacceptable. The organisation has not completed any decoration work. The inspector looked around the home and found the same problems. Wallpaper in bedrooms was damaged, paintwork in corridors and external parts of the building was peeling or damaged or dirty. Furniture was old and damaged. Four kitchen cupboards did not have any Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 16 doors on them. Ceiling and wall tiles were damaged and stained. One bathroom has a high/low 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. Staff have to hold a panel to stop it bending, at the back of the bath when it is being raised or lowered. 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. 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. Since the last inspection new carpets have been laid in the lounge and two bedrooms. Lockable cabinets have also been purchased for bedrooms and bathrooms. Staff working at the home have painted one bedroom. The home was very clean and tidy. There is some dispute between Bradford District Care Trust and Bradford Social Services about who is responsible for carrying out maintenance/improvement work at the home. This has resulted in the home’s general maintenance and decoration being neglected. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 17 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 & 36 Training for staff is very good, they have opportunities to attend courses that increases their knowledge and expertise in the learning disability field. Staff are appropriately supervised. EVIDENCE: In addition to basic training, staff working at the home have opportunities to attend training that equips them with skills and knowledge specific to people who use the service. Staff have recently various courses including, person centred planning, valuing people, epilepsy, autism, autism and communication and adult protection. All staff complete a learning disability qualification when they start work at the home. Twenty staff work at the home, ten of those staff have completed NVQ level 2 or above. The national minimum standards state that 50 of care staff should achieve the award. This target has been reached. The last inspection identified that staff records, which must be kept in the home, were not available. Since the inspection, the manager has obtained copies of the relevant information. Two staff files were looked and all the relevant information was available. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 18 Staff and the manager said monthly supervision is provided to all staff. The manager is responsible for co-ordinating supervision sessions. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 19 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): 37 & 42 A well organised and competent manager manages the home. The health and safety of service users and staff are protected. EVIDENCE: During the inspection the manager demonstrated good organisational skills. Staff also confirmed that manager was well organised. She also demonstrated a good knowledge of individual service users and clearly has regular input with them. She has recently finished NVQ level 4 in care and is starting NVQ level 4 in management. The manager anticipates she will finish the award in the next twelve months. Health and safety records were looked and regular checks are carried out. Staff attend regular training in key health and safety areas. Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 3 X X X X 3 X Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 21 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 2 Standard YA6 YA22 Regulation 15 22 Requirement Service user plans must be reviewed at appropriate intervals. The registered provider must ensure details of the CSCI are included in the complaints procedure. (Timescale of 31st October 2005 not met) 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 and 31st December 2005 not met) The registered provider must ensure the home has suitable bathing/ showering facilities to meet the needs of service users. (Timescale of 31st October 2005 not met) 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. (Timescale of 30th September 2005 not met) Timescale for action 31/03/06 31/03/06 3 YA24 23 31/03/05 4 YA27 23 31/03/06 5 YA30 16 31/03/06 Copwood Respite Unit DS0000046758.V273942.R01.S.doc Version 5.1 Page 22 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. 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