CARE HOMES FOR OLDER PEOPLE
Coumes Brook Cockshutts Lane Oughtibridge Sheffield South Yorkshire S35 0FX Lead Inspector
Sue Turner Key Unannounced Inspection 4th June 2008 08:00 X10015.doc Version 1.40 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 Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Coumes Brook Address Cockshutts Lane Oughtibridge Sheffield South Yorkshire S35 0FX 0114 286 2211 F/P 0114 286 2211 none 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) Coumes Brook Home Limited Mrs Amanda Jill Crookes Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th June 2007 Brief Description of the Service: Coumes Brook is a purpose built care home providing personal care for up to 24 older people of both sexes. The home is located in the village of Oughtibridge. All of the accommodation provided is on the ground floor. A communal lounge, dining room and conservatory are provided. A central kitchen and laundry serve the home. Twenty-one single and two double rooms are provided. All of the rooms have en-suite toilet facilities. Seventeen bedrooms have en-suite shower facilities. The entire home is accessible to residents. The gardens are landscaped and a patio area is provided. The home has a car park. A copy of the previous inspection report was available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of fees from 1st April 2008 were £400 £430 per week. Additional charges included newspapers, hairdressing and private chiropody. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes.
At feedback we gave guidance to the registered manager/provider about the progress that would have to be made so that in future this services quality rating could be improved. This was an unannounced key inspection carried out by Sue Turner, regulation inspector. This site visit took place between the hours of 8:00 am and 2:45 pm. The registered manager/provider is Jill Crookes, who was present during the site visit. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. We received six from people living in the home, five from relatives and six from staff. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Four staff, two relatives and ten people living in the home were spoken to. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last key inspection in June 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 6 What the service does well:
People living in the home said that the care they were receiving was good. They made comments such as: “The standard here is good, in fact I think it’s the best it’s been in five years”. “The staff are very nice and really helpful”. “There’s nothing I don’t like about the home”. “I think everyone’s been really good to me”. “I am quite satisfied and happy”. “Most staff are nice but there’s the odd one that I don’t like”. Comments received from questionnaires and from talking to relatives were in the main positive and included: “Staff are always on hand to answer any queries”. “There will always be limitations but generally the care service does as good a job as possible to support people leading an independent life for as long as possible”. “I am generally happy with the care and support given”. “My mother is treated kindly and sensitively by the staff and managers at the home”. “We have seen other care homes and this is by far the best one”. “The staff are always friendly, patient and approachable”. “The staff are on the whole good. There are some that mum doesn’t get on with”. The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. People’s health care was monitored and access to health specialists was available. People confirmed that staff were always respectful towards them. People said that they had a choice of food and that the quality of food served was “well cooked with just the right amount” and “ I always enjoy my food”. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 7 There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept “immaculately clean” and “very tidy”. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. Staff supervision took place, to support and give guidance to staff on an individual basis. Mandatory training took place, to equip staff with the essential skills needed. Records within the home were stored securely, to safeguard confidentiality. What has improved since the last inspection?
At the last inspection thirteen requirements were issued. Nine of these have either been actioned or are listed as recommendations in this report. The remainder are carried over into this report with a short timescale for completion. At feedback we discussed with the registered manager/provider the importance of ensuring that she acts in accordance with these requirements so that people are kept safe. People were being to some degree protected by the homes policies and procedures for dealing with medications. People self administering their medications were keeping their medications in a lockable facility. All cupboards and drawers that housed medications were kept locked. People said that they were aware of the choices available to them in regard to where they ate their meals. People were being offered a wider range of food choices, which ensured that they were receiving a healthy and balanced diet. Staff had undertaken training in adult protection procedures. Some staff required further updated and refresher training. People were not being moved around in wheelchairs without footplates in place. Substances that could be hazardous to health were being kept locked away at all times.
Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. 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. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 5. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Contracts were drawn up with each person to inform them of their rights and obligations. The information available, that would help people to decide if the home was right for them was not easy to read and some information was out of date. People’s needs were assessed prior to admission. EVIDENCE: Information was available about the home and the services offered. Looking through a number of documents for example, a brochure, the original Statement of Purpose (written in 2004) and other loose papers that had snippets of updated information, it was evident that some details were incorrect. Because the information was spread around it was also difficult to understand. We advised the manager that information provided about the home should be collated into a more easily read format.
Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 11 Six surveys were returned from people living in the home. When asked have you received a contract? Five people said “yes” and one person didn’t answer. We saw that people had either a social services contract or a private contract on their file. When someone showed an interest in the home the manager carried out a pre assessment. This meant that they could be assured that they could meet the person’s needs. People were invited to visit the home, try out the meals and spend time meeting the staff and seeing the services available. People said: “I’d heard good things about the home so my friend came and looked around. She knew it would be OK for me”. “I was recommended by a friend and came for the day. I was lucky because there was a place for me”. This home does not provide intermediate care services. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s 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. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were happy with the way staff delivered their care however lack of adequate recordings could put people at risk. The arrangement for the administration of medication was not robust and could pose a risk to people. The health and personal care needs of people were met in a way that respected their privacy and dignity. EVIDENCE: People living in the home had an individualised plan of care. Two peoples plans of care were checked. Care plans contained information on aspects of personal, social and health care needs. The care plan was developed at the time of the person’s admission. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 13 One person’s file seen did not identify that he/she had recently become ill and needed more care and attention. Staff were fully aware of the persons changing needs and were caring for them appropriately, but this wasn’t recorded in their care plan. Dates were recorded in the care plans of when they had been reviewed. However following reviews there was no evidence that any changes were made to the care plans. Staff completed daily records. These were done at the end of each shift. There was very little information in the daily records. Those seen were short, brief comments that were repetitive. Records didn’t detail how people had spent their day, what meals they had taken, if any visitors were seen, any personal care tasks undertaken and any activities they had joined in. Daily records did not link with the information recorded in peoples care plans. Two relatives said that they had not been invited to contribute to their relatives care plan or review. One relative survey said: “Staff have rung me when mum has been anxious”. Care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists visited the home as requested. When visited by a health professional any changes made to a person’s health needs wasn’t always transferred into the persons care plan. When asked, “are you kept up to date with important issues e.g. accidents and hospital admissions four relatives said “always” and one said “usually”. When people were asked do you receive the medical support you need? Five people said “always” and one said “usually”. One relative said: “The home has good links with the local medical centre and see that medical help is sought whenever necessary”. Medicines were securely stored around the home in locked trolleys within cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Staff said that they had to complete competence training before they were allowed to administer medications. There was evidence that the manager and senior staff were auditing medication administration procedures. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 14 Controlled drugs (CD) were kept in a clinical room and within a double locking cabinet. A CD register was available. We observed a senior carer administering medications at breakfast. Some people were given their medication in the middle of eating their meal. One person was administered their tablets, which were then left on the table for them to take. Another person’s tablets were left on their breakfast tray in their bedroom. When asked about this the carer said that this was because these people asked for their tablets to be left for them to take at their convenience. The manager said that this was common practise. The risks associated with this practise were discussed with the manager and senior carer. People and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. Staff were observed speaking to people in a respectful way and showed empathy and patience when providing personal care to them. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A limited range of activities was on offer, further activities would promote choice and maintain peoples interests. Meals served at the home offered choice and ensured people received a healthy balanced diet. EVIDENCE: People were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. We saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. Some people said they preferred to stay in their room at certain times of the day and that the staff respected their decision. People were proud to have their own TV in their bedroom so that they are able to watch programmes of their choice whenever they wished to do so.
Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 16 Care staff at the home had the responsibility of carrying out activities, which although they enjoyed, added to their tasks. Staff rotas were sometimes difficult to cover due to sickness, resulting in activities being the first thing that would be disregarded. The manager said that she had decided to employ an activities worker. We agreed that this would enhance people’s social life and reduce the burden on carers. People said: “More outings are needed” “Light exercises are needed” “More activities are required”. “I’ve been on a couple of trips and would love to go on more”. “There aren’t many activities, I try to keep busy doing my puzzles”. When asked are there activities arranged by the home that you can take part in? Five people said “sometimes” and one said “usually”. Relatives said: “The care home could improve by encouraging more social activities, although I have seen that opportunities are sometimes not taken up when offered which is personal choice”. “I would like to see more activities taking place”. On the day of the site visit, we observed breakfast and lunch being served. Many people chose to eat breakfast in their room. This was nicely served on a tray with individual teapot, milk and sugar. People had a choice of cereals, porridge or grapefruit followed by bread or toast with preserves. There was no cooked breakfasts served, which some people said was “disappointing”. The manager said there was no reason why people couldn’t be offered a cooked breakfast on some days and she would make this available. The cook went around each morning and asked people what they would like for lunch. There was one main choice and if people didn’t want this, the cook was happy to provide alternatives. People said that they had ample amounts of food to eat and the quality of the food served was “good”, “excellent” and “tasty”. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 17 The dining room tables were set nicely with cloths, napkins, cutlery and matching crockery. The dining room was quite small and had a pleasant relaxed ambience. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. 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. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people felt confident that any concerns they voiced would be listened to. The majority of staff had received adult safeguarding training. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall and bedrooms. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. Relatives spoken to said that they felt very comfortable in going to any member of the staff or the manager, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had not received any complaints since the last inspection. We had not received any complaints about the service.
Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 19 When people were asked do you know how to make a complaint? All six people said “yes”. Relatives said: “I have always felt able to approach staff about any concerns”. “I would hope that any concerns or complaint would be dealt with in the first instance on a face to face basis. There is however a procedure for formal complaints”. An adult protection policy and procedure was in place. The majority of staff had undertaken training on adult protection. Some staff had completed adult protection training, but this was quite some time ago and they would benefit from attending refresher courses. In conversation with staff, we noted that they had an understanding of safeguarding adults and whistle blowing policies, procedures and practices. People said they felt safe living at the home. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. 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. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and well maintained, providing a pleasant environment for people and their visitors. EVIDENCE: The home is surrounded by very pleasant woodland, which had a variety of shrubs and flowers. The conservatory leads onto a pleasant sitting area where a water feature was being built which would add to the appeal of the outside grounds. Many rooms overlooked the grounds and people said they got great pleasure from looking out of their windows and sitting outside in the nice weather.
Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 21 The home was very clean and tidy. Lounge and dining areas were domestically furnished to a high standard. The manager had a programme of refurbishment and redecoration that ensured that the home was very aesthetically pleasing. The manager said that she would carry out any work deemed necessary for the comfort and well being of the people living in, working and visiting the home. Bedrooms checked were spacious, comfortable, homely and reflected peoples personal tastes. People said their beds were comfortable and bed linen checked was clean and in a good condition. No unpleasant odours were noticeable in the home and relatives said that the home was always kept “immaculately clean”. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. When people were asked is the home clean and fresh? Five people said “always and one said “usually”. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. 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 home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers and had completed induction training. Some staff required refresher training to ensure their skills were kept up to date. The shortfalls in the information obtained during staff recruitment meant that people were not adequately protected. EVIDENCE: Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. On the day of the site visit staffing numbers were at an acceptable level. Staff said that there were usually enough staff on duty to meet the individual needs of people. They said: “In unforeseen circumstances when staff phone in sick there are not always enough staff at short notice”. “Staffing levels are not a problem on the whole. People let each other down by going off sick, but the remaining staff pull together very well”.
Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 23 When asked, are the staff available when you need them? Five people said “always” and one said “usually”. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, First Aid and Fire. 42 of the staff team had achieved their NVQ Level 2 or above, however this did fall below the recommended 50 trained staff. Six staff surveys were returned, when asked are you being given training, which is relevant to your role? Five said, “yes” and one person said “no”. One staff said: “I am currently doing my NVQ Level 3, I find this training very helpful”. Three staff records of employment were checked. POVA checks had been made and CRB checks had been obtained for the staff members. There were shortfalls in the information that should have been gathered during the recruitment process. Two people had supplied one reference each and there were no references for one person. References obtained were not from the person’s previous employer. The significance of obtaining references for people, before they commence work was reiterated to the manager. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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 home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were overall, benefiting from the management approach of the home. People’s health and safety had not been promoted and protected in some areas. EVIDENCE: The registered manager/provider had completed NVQ Level 4 in Management. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager/provider at
Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 25 any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. As registered manager/provider there is no reason why all of the requirements from the previous report have not been actioned. The severity of the issues carried over have consequently prevented the home being of a higher quality rating. The manager/provider said she had not carried out a quality assurance review for some time. People, staff and relatives said that meetings were not happening on a regular basis. The manager agreed that this was an area for development and would be actioned as part of the quality assurance implementation. Some people held their own money and they had a lockable drawer in their room where they could hold this money safely. Personal allowances were held on behalf of some people. We checked the records held for three people against balances of monies held and all were correct. Receipts were not obtained for all money paid out. The manager said she would review this so that receipts were requested and kept on people’s files. Formal staff supervision, to develop, inform and support staff took place at regular intervals. Staff said that they found this useful and beneficial. At the previous inspection the manager/provider was unable to produce any certificates to confirm that the gas and electrical installations had been serviced, although certificates were seen regarding the electrical PAT (portable appliance testing) checks. The manager said that this work had been carried out and she would chase-up the certificates. A requirement was issued that they were provided for 01/08/07. At this site visit the certificates were still not provided. This places people, visitors and staff at risk. Following the site visit the provider said that gas and electrical installations had been checked. Certificates to confirm this were also forwarded to us. At the previous inspection people were observed using wheelchairs without footplates fitted. At this site visit people were seen with footplates in situ on their wheelchairs. Fire records evidenced that weekly fire alarm checks took place. This was in line with the fire services recommended ‘weekly’ check. Staff said fire drill training took place on a regular basis and we saw evidence of this. All hazardous substances were kept locked in cupboards. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X 4 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must be updated to ensure that they reflect the current health, social and personal needs of each person. (Previous timescale of 01/08/07 not met). People and/or their representative must be involved in the care planning and reviewing process. To fully protect peoples health, safety and welfare: When medications are handed to people, staff must ensure that they are taken straight away. Staff should only sign to confirm they have administered medications when they have observed people taking their medication. To fully protect people two written references, one from the previous employer, must be obtained for all prospective members of staff. (Previous timescale of 01/08/07 not met). The homes quality assurance system must be developed
DS0000002950.V364159.R01.S.doc Timescale for action 01/08/08 2. OP7 15 01/08/08 3. OP9 13 04/06/08 4. OP29 19 01/07/08 5. OP33 24 01/08/08 Coumes Brook Version 5.2 Page 28 6. OP35 16 7. OP38 23 further. The performance of the home must be monitored against the Statement of Purpose and The Care Homes Regulations. Any identified patterns or issues requiring action must be dealt with appropriately. Adjustments to improve the service must be made if necessary. (Previous timescale of 31/12/07 not met). Where the money of individual people is handled, receipts must be kept for all transactions. This will ensure that their finances are safeguarded. Certificates to confirm that the gas and electrical installations have been serviced as required by the health and safety and insurance policies must be provided. Copies of these certificates must be sent to the CSCI office by the timescale agreed. (Previous timescale of 01/08/07 not met). 04/06/08 16/06/08 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. 2. 3. 4. Refer to Standard OP1 OP9 OP12 OP12 Good Practice Recommendations The information provided to people prior to admission should be revised to make it easier for people to read. All staff that administers medication should undertake accredited training. An activities worker should be recruited so that the programme of outings and activities is enhanced. A further programme of activities should be developed to include a wider and more frequent range of activities. People should be consulted on their preferences, and
DS0000002950.V364159.R01.S.doc Version 5.2 Page 29 Coumes Brook 5. 6. 7. 8. OP15 OP18 OP28 OP33 activities provided should be recorded and monitored. The option of a cooked breakfast should be made available. To further ensure the protection of all people, staff should undertake updated and refresher courses in adult safeguarding. There should be 50 of the care staff trained to NVQ Level 2 or equivalent. Regular resident, staff and relative meetings should take place. Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Coumes Brook DS0000002950.V364159.R01.S.doc Version 5.2 Page 31 - 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!
