Inspection on 08/03/04 for Coton House

Care Home For Older PeopleCoton Care LtdCoton House 55 Coton Road Penn Wolverhampton West Midlands WV3 7LZAnnounced Inspection8th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. FINAL ­ UI Coton House ­ 08.03.04ESTABLISHMENT INFORMATION Name of establishment Coton Care Ltd Address Coton House, 55 Coton Road, Penn, Wolverhampton, West Midlands, WV3 7LZ Email Address Name of registered provider(s)/Company (if applicable) Mr Balbir Singh Kular Mrs Inderjit Kular Name of registered manager (if applicable) Mrs Kalwant Chatal Type of registration Care Home Tel No: 01902 339391 Fax No: 01902 339391No. of places registered (if applicable) 21Category(ies) of registration, with (number of places) Old age, not falling within any other category (21) Registration number E080000051 Date First registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 07/11/03 If Yes Refer to Part CCoton Care LtdPage 1 FINAL ­ UI Coton House ­ 08.03.04 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 3 8th March 2004 08:30 am Ms Maggie Bennett 073477 ID CodeName of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Mr. Balbir Singh Kular and Mrs. Kalwant Chahal. the time of inspectionCoton Care LtdPage 2 FINAL ­ UI Coton House ­ 08.03.04 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementCoton Care LtdPage 3 FINAL ­ UI Coton House ­ 08.03.04 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Coton Care Ltd. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Coton Care LtdPage 4 FINAL ­ UI Coton House ­ 08.03.04 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Coton House is situated in a very quiet area of Penn, some 400 yards from Goldthorn Hill. The property was built in the 1930s and has been a residential home for the elderly for many years. In 2001 the Home had major development and refurbishment with a new purpose built wing of 10 en-suite bedrooms being added. Coton House is registered for 21 service users aged over 65 years . The home is well maintained and has a homely, friendly atmosphere. The staff are experienced and committed to meeting the care needs of the service users.Coton Care LtdPage 5 FINAL ­ UI Coton House ­ 08.03.04PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Choice of Home (Standards 1-6) 2 of the 4 standards assessed were met. Standard 1 was not assessed as it was met at the unannounced inspection. The home have devised a statement of terms and conditions/contract which meets the majority of this standard. The statement must, however, be clear about what the fees paid cover and do not cover. There is evidence that all prospective service users are given the benefit of a comprehensive assessment before they are admitted to Coton House. The home needs to ensure that all those areas listed in Standard 3.3 are assessed where service users are privately funded. Following assessment, the registered manager must write to the prospective service user confirming that the home is able to meet their needs. There are good training opportunities at the home, which assist the staff to meet the assessed needs of their service users. There is evidence that service users new to the home are given opportunities to flexibly test out the home before moving in. Coton House does not provide intermediate care. Health and Personal Care (Standards 7-11) 4 of the 4 standards assessed were met Standard 7 was not assessed as it was met at the unannounced inspection. There are good systems in place to ensure that service users healthcare needs are met, regularly reviewed and updated. There has been an improvement in this area since the unannounced inspection. The home states that it enjoys an excellent relationship with visiting healthcare professionals. The standard with regard to medication administration procedures is now met. The home have installed a suitable fridge for the storage of insulin and have satisfactory arrangements for the storage and administration of controlled drugs. All senior staff have successfully completed the Safe Handling of Medicines training at Wolverhampton College. All service users have their own rooms and there was evidence during the inspection that their privacy and dignity is respected. Several service users expressed their satisfaction with the quality of care provided by staff. Daily Life and Social Activities (Standards 12-15) 4 of the 4 standards assessed were met. During the inspection service users confirmed that they were given choices with regard to both the regular events in the home and the entertainment and trips out. Several visitors were at the home during the inspection, one of whom confirmed that he was able to come at any reasonable time. There are links with the local community through the church and a local choir. Service users are given the opportunity to manage their own financial affairs for as long as they wish to do so. The home has links with the Age Concern Advocacy Service who are able to visit to assist service users. The majority of service users spoken to at the inspection were very happy with the quality and quantity of the food provided. Not all Coton Care Ltd Page 6 FINAL ­ UI Coton House ­ 08.03.04 appeared to be aware that there was a choice for the main meal of the day. There was evidence that attention is given to specific dietary needs, likes and dislikes. One service user is given the opportunity to buy their own food with assistance from their keyworker. Complaints and Protection (Standards 16-18) 3 of the 3 standards assessed were met. The home have a complaints procedure, a copy of which is given to service users and their relatives. One complaint remains unresolved, but this is beyond the control of the home, who have co-operated fully in the investigation. All service users are on the electoral register and assisted to vote if they wish. The home have a clear Adult Protection Procedure as well as a copy of the local Social Services Procedure. Staff training is provided in adult protection. Environment (Standards 19-26) 5 of the 8 standards assessed were met. Although records are kept of maintenance work carried out, there is no programme of planned maintenance and renewal with projected dates. An action plan is required, particularly in respect of the replacement of window frames, the provision of a bathing or showering facility on the first floor, the provision of radiator covers in all rooms (several have already been done on a risk assessment basis) and boxing in of pipe work. Although the home have as yet been unable to obtain the services of an occupational therapist to assess the premises and facilities, the inspector is satisfied that steps have been taken to access this service. All service users have single rooms, which are well equipped and personalised to individual taste. The home was warm and comfortable at the time of the inspection, but it was noted that portable heaters are used in two bedrooms. It is recommended that regular checks are made in these rooms as more efficient fixed radiators may be needed. There are good policies and procedures in place for the control of infection. Staffing (Standards 27-30) 2 of the 3 standards assessed were met. Staffing ratios meet the requirements of the Commission. The home have been recommended to consider that the daytime shift numbers (three) remain until 10.00 p.m., rather than 9.00 p.m. as at present. All staff are enrolled on NVQ training at present and the home have already exceeded this standard. Generally staff records are in good order, but there were some omissions and statutory requirements have been made, to ensure that these are addressed. Management and Administration (Standards 31-38) 6 of the 7 standards assessed were met. The registered manager is very experienced and is currently undertaking the NVQ4 in care. This will be followed with the Registered Managers Award. It was clear during the inspection that both the registered provider and registered manager are liked and well respected by both service users and staff. Staff appeared committed and enthusiastic and felt that they made a good team. There are systems in place for measuring the service users, relatives and visiting professionals views of the home. The registered provider must provide the Commission with a monthly report on the conduct of the home. Service users personal monies are kept in good order with appropriate records and receipts kept. Staff supervision takes place at regular intervals. Training in the core safety areas takes place regularly. There is evidence that regular servicing and checks on equipment take place. Coton Care Ltd Page 7 FINAL ­ UI Coton House ­ 08.03.04 Staff receive induction and foundation training to TOPSS specifications on safe working practice topics.Coton Care LtdPage 8 FINAL ­ UI Coton House ­ 08.03.04 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 23(2)(p) OP25 Ensure all pipe work throughout the building is 31/08/04 insulated or boxed and that all the radiators are fitted with protective guards or specialist low surface temperature radiators.Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Coton Care LtdPage 9 FINAL ­ UI Coton House ­ 08.03.04 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 5(1)(b) OP2 The statement of terms and conditions must be clear on what the fees do and do not cover. The home must ensure that all the areas listed in Standard 3.3 are included in their assessment of privately funded service users. Following assessment, the registered manager must write to the service user confirming that the home is able to meet their needs. The home must have a planned programme of routine maintenance and renewal of the fabric and decoration of the premises with projected dates for completion. The maintenance and renewal plan must include details of projected dates for the renewal of metal window frames. Alternative suitable storage space must be made available for wheelchairs currently stored in the ground floor bathroom. The rusting toilet frame in the ground floor bathroom must be replaced. 19/04/04214(1)OP319/04/04314(1)(d)OP319/04/04423(2)(b)OP1919/04/04523(2)(b)OP1919/04/04623(2)(l)OP2119/04/04716(2)(c)OP2119/04/04Coton Care LtdPage 10 FINAL ­ UI Coton House ­ 08.03.04 8 9 10 11 23(2)(j) 13(4)(c) Schedule 4, 6 Schedule 4, 6 OP21 OP25 OP29 OP29 There must be accessible bathing and showering facilities for all service users. The radiator cover in Room 8 must be repaired. A reference must be obtained from the last employer for all new staff. Staff records must include a copy of the persons birth certificate and passport. The registered person must prepare a report on the conduct of the home following his monthly visits, a copy of which must be supplied to the Commission. 31/08/04 19/04/04 19/04/04 19/04/041226OP3601/04/04Coton Care LtdPage 11 FINAL ­ UI Coton House ­ 08.03.04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 2 3 4 OP2 OP21 OP24 OP24 A copy of the statement of terms and conditions/contract should be kept on the service users file. It is strongly recommended that consideration is given to converting the first floor bathroom (currently unassisted) into an assisted shower room. It is recommended that consideration is given to providing washable floor covering in one bedroom (number notified to registered person). It is recommended that redecoration takes place in Room 2. It is recommended that the temperature of bedrooms where portable radiators have been installed are regularly monitored to ensure that service users are warm enough. If necessary, existing radiators should be upgraded. It is recommended that the supply of hot water to one room (number notified to registered person) is regularly monitored. It is recommended that consideration is given to day time staff (three care workers) being on duty until 10.00 p.m.5OP256 7OP25 OP27* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Coton Care LtdPage 12 FINAL ­ UI Coton House ­ 08.03.04PART BINSPECTION METHODS & FINDINGSYES YES YES YES YES YES NO NA YES YES YES YES NO YES YES YES NO YES NO YES 8 1 0 YES YES YES YES 14 0 08/03/04 08:30 8.0The following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs)Coton Care LtdPage 13 FINAL ­ UI Coton House ­ 08.03.04 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Coton Care LtdPage 14 FINAL ­ UI Coton House ­ 08.03.04Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service Users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 291.00 To (£) 318.00Any charges for extrasYESIf yes, please state what the extras are: Personal toiletries, own newspapers and magazines, private chiropody. Key findings/Evidence Standard not assessed on this occasion.Standard met?0Coton Care LtdPage 15 FINAL ­ UI Coton House ­ 08.03.04 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 2 Key findings/Evidence Standard met? Each service user is provided with a statement of terms and conditions (or contract if they are purchasing their care privately) when they move into the home. This statement contains the majority of the required information. The statement must be clear on what the fees do and do not cover. A copy of the statement or contract should be kept on the service users individual file. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? Prospective service users are assessed by the registered manager prior to being admitted, either in their own home or in hospital. A copy of the care management assessment is received from the social worker. The home must ensure that all the areas listed in Standard 3.3 are included in their assessment of privately funded service users. Following assessment, the registered manager must write to the service user confirming that the home is able to meet their needs. There was evidence at the inspection that all service users have their own plan of care, which is developed from the assessment information. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Although the home does not offer a specialist dementia service, some service users do have mild dementia. Staff have received training in dementia care. The needs of one service user are monitored by a visiting Community Psychiatric Nurse. Some of the staff are able to speak some Asian languages and it was observed at the inspection that specific cultural and communication needs are met. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? All prospective service users are given the opportunity to spend time in the home, perhaps having a meal, prior to making a decision to move in. Families and friends are also invited to visit. There is a 28-day settling in period prior to a review meeting being held. The inspector was informed that emergency admissions are rarely made, but that if one were to take place, the home would ensure that it followed the recommendations of Standard 5.3.Coton Care LtdPage 16 FINAL ­ UI Coton House ­ 08.03.04 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard is not applicable to Coton House.Coton Care LtdPage 17 FINAL ­ UI Coton House ­ 08.03.04Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Coton Care LtdPage 18 FINAL ­ UI Coton House ­ 08.03.04 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)12 03 Key findings/Evidence Standard met? All service users have a medical profile on their service user plan. This is comprehensive and includes details with regard to food likes/dislikes and allergies and an assessment of risk of pressure areas. The home has both a bath hoist and manual hoist. Professional advice with regard to continence promotion is available from the continence nurse. Advice with regard to psychological health is provided by the community psychiatric nurse. Service users have the opportunity for light exercise with staff, who carry out short sessions on a daily basis and a monthly visit from NJR Fitness. All service users are regularly weighed. If possible, service users are able to retain their own G.P. when they move to the home. The dentist and optician visit regularly. The majority of service users have access to the NHS Chiropodist, although some choose to pay privately. From the service user files seen at the inspection, it could be seen that there has been an improvement in healthcare plans since the unannounced inspection. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The home now have a policy with regard to the receipt, recording, storage, handling, administration and disposal of medicines. None of the present service users choose to take charge of their own medication, although all have a lockable facility in which to keep the medication, if they wish. The home now have an appropriate fridge for certain medications, the temperature of which is checked three times a day. Controlled drugs are stored in a metal cupboard and administered by designated and appropriately trained staff. All senior staff have successfully completed the Safe Handling of Medicines training at Wolverhampton College. The Pharmacist visits four times a year and carries out an audit. A sample of medication and administration records were seen at the inspection and there were no discrepancies.Coton Care LtdPage 19 FINAL ­ UI Coton House ­ 08.03.04 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? All service users at Coton House have single rooms and, with the exception of one room, all have an en suite toilet. There is a payphone available in the hall and service users are able to use the office to make and receive private calls. A number of service users have had private phones installed in their rooms at their own expense. Service users are asked at the point of assessment how they wish to be addressed. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Service users wishes with regard to terminal care and arrangements after death are obtained at the assessment stage, if possible. Family members are involved in these discussions if appropriate. Unless there are medical reasons for not doing so, service users are able to spend their final days in their own rooms. Bereavement counselling is available locally. Where the needs of service users change, re-assessments are requested. The home have clear policies with regard to dying and death.Coton Care LtdPage 20 FINAL ­ UI Coton House ­ 08.03.04Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Service users confirmed during the inspection that they are given choices with regard to the daily routines of the home and whether or not they wish to join in activities. The homes records with regard to their social activities programme were seen at the inspection. Recent trips out have included Rhyl (last summer), the Safari Park, a Christmas meal and garden centres. Up to date information with regard to activities is posted on the notice board and also communicated verbally to service users. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? Service users are able to receive their visitors at any reasonable time and are able to choose whom they see and do not see. The service user guide contains information for friends and relatives on the homes policy with regard to maintaining relatives and friends involvement. There are links with the local community through a local choir and church. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users have the opportunity to manage their own financial affairs for as long as they wish to. All have been given information on the local Age Concern Advocacy Scheme. There is evidence that service users are able to personalise their rooms and bring furniture with them, as long as it meets the requirements of the Fire Officer. Arrangements with regard to access to personal records are stated in the Service User Guide.Coton Care LtdPage 21 FINAL ­ UI Coton House ­ 08.03.04 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Menus seen at the inspection indicated that a variety of nutritious foods are offered. Not all service users were aware that a choice is always available, particularly for the main meal of the day. It is recommended that choices are stated on the menu. A cooked breakfast is provided on two days a week. The meal on the day of the inspection appeared appetising and was well received by the service users. Special needs, including diabetic diets and liquefied meals, are provided. Cultural dietary needs are also taken into account, with one service users key worker purchasing specific foods for the individual concerned. The meal on the day of the inspection took place in an unhurried and relaxed atmosphere, with discreet assistance being given where needed. Observation of the food stores showed adequate supplies. Meat, fresh vegetables and fruit are delivered on a daily basis.Coton Care LtdPage 22 FINAL ­ UI Coton House ­ 08.03.04Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 1 0 0 0 1 0 100 3 Key findings/Evidence Standard met? The home have a clear complaints procedure which meets the requirements of this Standard. No complaints have been made since the last inspection. All service users are given written information on how to make complaints.Coton Care LtdPage 23 FINAL ­ UI Coton House ­ 08.03.04 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? All service users are on the electoral register. Those service users who wish to are taken to vote and others have the opportunity of a postal vote. The Age Concern Advocacy service is available locally.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X3 Key findings/Evidence Standard met? The home have their own Adult Protection Procedure in addition to a copy of the Wolverhampton Social Services procedures. These include Whistleblowing procedures. The registered provider is attending training in adult protection in the near future. The home is recommended to ensure that they have a copy of the Department of Health document, No Secrets. The home have a policy with regard to physical and/or verbal aggression by service users. There are clear policies with regard to service users monies and valuables. Staff are made aware of these policies at induction. If necessary an Advocacy Service is available for service users requiring advice with regard to wills.Coton Care LtdPage 24 FINAL ­ UI Coton House ­ 08.03.04EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Coton House is situated in a quiet residential area in Penn. On the day of the inspection it was clean, warm and comfortable. Although the home has records of maintenance work carried out, there is no written programme of routine maintenance and renewal of the fabric and decoration of the premises. It was noted that some tiles in the roof of the stairwell need replacing. It was further noted that a number of the old metal window frames are now in need of replacement and the registered person is required to state in the Action Plan details of when these windows are to be replaced. There is a very attractive, well maintained garden. The Fire Officer visited in October 2003 and The Environmental Health Officer in May 2003. The registered person states that their recommendations have all been met. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? There is sufficient communal space within the home, with a lounge, dining room and conservatory. As stated above, there are attractive gardens. Furnishings in the communal areas are all of good quality.Coton Care LtdPage 25 FINAL ­ UI Coton House ­ 08.03.04 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? All service users have single rooms and all but one have an en suite toilet facility. There are additional toilets within the home. There is one assisted bath on the ground floor and the inspector was informed that this is used by the majority of service users. Wheelchairs currently stored in this bathroom must be stored elsewhere. The rusting toilet frame in this bathroom must be replaced. It is a requirement that service users should have access to sufficient bathing or showering facilities. Currently service users with rooms on the first floor are using the only assisted bathroom on the ground floor, some distance away from their rooms. This ground floor bathroom is being shared by all 21 service users. The unassisted bathroom on the first floor is rarely used. It is strongly recommended that consideration is given to converting this bathroom into an assisted shower room. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The home provides a number of items of equipment to assist service users, including a bath hoist and manual hoist. There is a call system with an accessible alarm facility in each room. The home have been unable to obtain the services of an occupational therapist to assess the premises and facilities. The registered person was, however, able to provide evidence that he is continuing to pursue this and has written to New Cross Hospital Occupational Therapy Department and to the Local Authority Occupational Therapy Department.Coton Care LtdPage 26 FINAL ­ UI Coton House ­ 08.03.04 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 21 20 0 0 21 00 1 0 03 Key findings/Evidence Standard met? All service users have a single room and all but one have an en suite toilet. All have wash hand basins.Coton Care LtdPage 27 FINAL ­ UI Coton House ­ 08.03.04 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Service users are able to bring items of furniture from home if that is their wish and as long as it meets the requirements of the Fire Officer. Individual rooms seen at the inspection were personalised to individual taste. All rooms are equipped with sufficient furniture. Where those items listed in Standard 24.2 are not provided (such as two easy chairs and a table to sit at) this is as a result of discussion with the service user and their family or a risk assessment. This information is recorded in the service user plan. Service users are provided with keys to their rooms. The registered person is recommended to consider providing washable floor covering in one room (no. notified to registered person). If this is not considered acceptable by the service user, a new carpet must be provided. Some redecoration is required in Room 2 where it was noted that wallpaper was peeling in one area and the wall next to the laundry appeared to have condensation marks. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? All individual bedrooms have natural ventilation. As stated earlier, some of the existing metal window frames must be replaced. All rooms are centrally heated and there is a rolling programme to ensure that radiators are covered. A risk assessment has been carried out and the most urgent have been given priority. The registered person must provide information with regard to the timescale for radiator covers and the boxing in of pipework. It was noted that there was no cover on the radiator in Room 12A and that the head of the bed was against the radiator. The radiator cover in Room 8 needs repair. Service users are able to control the temperature of the radiators. It was, however, noted that additional portable radiators were provided in two rooms and the registered person is required to check that service users are warm enough in these rooms. One service user said that their room was sometimes chilly. At the time of the inspection there was a very poor supply of hot water to one room. This was attended to during the inspection. The registered manager is recommended to monitor this on a regular basis. Water temperatures at outlets accessible to service users are checked each week and recorded.Coton Care LtdPage 28 FINAL ­ UI Coton House ­ 08.03.04 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home was clean and free of offensive odours (apart from one bedroom) on the day of the inspection. The laundry contains an industrial washing machine, with sluicing and disinfection programme and a tumble dryer. There are hand washing facilities. There are policies in place with regard to the control of infection.Coton Care LtdPage 29 FINAL ­ UI Coton House ­ 08.03.04StaffingThe intended outcomes for the following set of standards are: · · · · Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 2 40 X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 4 15 X No. staff hours allocated No. staff hours allocated No. of staff hours provided 36 270 346.5 X X X0 12 23 Key findings/Evidence Standard met? The staff rota was seen at the inspection. It indicated that there are three care workers on duty between 7.30 a.m. and 4.00 p.m. and between 4.00 p.m. and 9.00 p.m. From 9.00 p.m. to 7.30 a.m. there are two waking night staff. The Managers hours are supernumerary. A cook and a cleaner are employed on seven days a week. These staffing levels meet the current requirements of the Commission. The registered persons are recommended to give consideration to day time staff being available until 10.00 p.m. as this may be the guidance of the Staff Calculation Tool to be used from April 2004. Coton Care Ltd Page 30 FINAL ­ UI Coton House ­ 08.03.04 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 6 50.1 4 Key findings/Evidence Standard met? Every member of staff at the home is currently on NVQ training. The home is therefore ahead of the target to have 50 of its staff trained to NVQ level 2 or equivalent by 2005. The home does not employ agency staff or have trainees.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? A sample of staff records were seen at the inspection. Staff records must include a copy of the persons birth certificate and passport. Two written references had been obtained for the majority. In one case the home must obtain a reference from the last employer. Criminal Records Bureau checks have been requested for all staff. Included in these checks is one for a volunteer employed at the home. All staff have been given copies of the General Social Care Council Code of Conduct and all receive statements of their terms and conditions of employment. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Coton Care LtdPage 31 FINAL ­ UI Coton House ­ 08.03.04Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The registered manager has twenty years experience in the caring profession. She is currently undertaking the NVQ4 in Care and will follow this with the Registered Managers Award. She has already successfully completed the D32/D33 Assessors Award. There is evidence that the Manager undertakes other periodic training to update her knowledge. The manager has a job description and there are clear lines of accountability within the home. There is a Deputy Manager with twelve years experience. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? From discussion with service users and staff it is clear that the registered manager is liked and well respected and communicates a clear sense of direction and leadership. There is a low staff turnover within the home and staff feel that they work well together as a team. Regular staff meetings are held. Staff are given written information on equal opportunities.Coton Care LtdPage 32 FINAL ­ UI Coton House ­ 08.03.04 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? Coton House successfully completed the Investors in People Award in December 2002. Questionnaires are sent to service users and visiting health and social care professionals. Similar questionnaires are sent to relatives. The results of these questionnaires are available in the service user guide. Service user meetings are held on a regular basis. Service users were given every opportunity to meet with the inspector and to speak in private. Policies and procedures are updated every three months. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The homes Business Plan was seen at the inspection and demonstrated an efficient management of the business. There is adequate insurance cover in place and current certificates were seen.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 2 0 03 Key findings/Evidence Standard met? Some service users request that the home keep in safekeeping some monies on their behalf. A sample of the records and receipts were seen at the inspection and all were in order. The registered manager does not act as appointee for any service user. All monies are kept in secure facilities.Coton Care LtdPage 33 FINAL ­ UI Coton House ­ 08.03.04 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? All staff receive supervision at least six times a year. The volunteer receives supervision from her trainer. The registered provider must provide a written report on the conduct on the care home following his monthly visits. A copy of this report must be supplied to the Commission.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? There was evidence that regular training is provided in the core areas of moving and handling, fire safety, first aid, food hygiene and infection control. Certificates were seen as evidence for the following: servicing of boilers and central heating system (29.90.03); maintenance of electrical systems (24.01.2004.); testing of electrical equipment; maintenance of the emergency call system (01.2004.); Servicing of the lift and electrical hoist (21.01.04.) and servicing of the manual hoist (18.04.03.). The registered person stated that checks for legionella were regularly carried out and the water temperatures were checked weekly. All service users are subject to a risk assessment. The home has a written statement on its arrangements for maintaining safe working practices. Staff receive induction and foundation training to TOPSS specifications on safe working practice topics.Coton Care LtdPage 34 FINAL ­ UI Coton House ­ 08.03.04PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateMaggie BennettSignature Signature Signature10/05/04Coton Care LtdPage 35 FINAL ­ UI Coton House ­ 08.03.04PART D(where applicable) N/aLAY ASSESSORS SUMMARYLay Assessor Date Public reportsN/aSignatureIt should be noted that all NCSC inspection reports are public documents.Coton Care LtdPage 36 FINAL ­ UI Coton House ­ 08.03.04PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCoton Care LtdPage 37 FINAL ­ UI Coton House ­ 08.03.04 Action taken by the NCSC in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection reportYESProvider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Coton Care LtdPage 38 FINAL ­ UI Coton House ­ 08.03.04 E.3 PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies. E.3.1 I Bal Kular of Coton House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Director 19/04/04 Bal KularPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Coton Care LtdPage 39 FINAL ­ UI Coton House ­ 08.03.04Coton Care Ltd / 8th March 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000020885.V131594.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!