CARE HOMES FOR OLDER PEOPLE
Coumes Brook Cockshutts Lane Oughtibridge Sheffield South Yorkshire S35 0FX Lead Inspector
Janis Robinson Unannounced Inspection 5th October 2005 12:30 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.V254777.R01.S.doc Version 5.0 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.V254777.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Coumes Brook Address Cockshutts Lane Oughtibridge Sheffield South Yorkshire S35 0FX 0114 286 2211 0114 286 2211 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 Wendy Jane Newman Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: Coumes Brook is a purpose built care home providing personal care for up to 24 older people of both sex. 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. 21 single and 2 double rooms are provided. All of the rooms have en-suite toilet facilities. 17 bedrooms have en-suite shower facilities. All of the home is accessible to residents. The gardens are landscaped and a patio area is provided. The home has a car park. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3 hours from 12.30 pm to 3.30 pm. A partial inspection of the environment took place. Records were sampled, including care plans, staff recruitment and training, medication, residents’ monies, contracts and the staff rota. The inspector spoke with all of the care staff on duty, seven residents and one professional visitor to the home. Care practices and the shift handover were observed. Discussions with the homes manager took place. The majority of standards were assessed and met at the last inspection. What the service does well:
All of the comments made by residents were very positive. Residents said the home was ‘the best in the country’, ‘can’t be better cared for’, and ‘the staff are wonderful’. Trial visits to the home, to enable prospective residents and their representatives to make an informed decision, were encouraged by the home. Each resident had been provided with a contract that contained relevant information. Staff undertook a range of training to keep them up to date and meet residents needs. Access to specialists was available. Each resident had a care plan, which outlined all personal, social and health care needs. Access to health care professionals was supported, to maintain residents health. Residents confirmed that the staff were respectful towards them. The routines at the home were flexible, residents were able to choose how to spend their day. The home had an open visiting policy, to maintain contact with residents and their family and friends. A varied diet was provided and choices were offered. Residents said ‘the food could not be better, nothing is too much trouble’. The home had a complaints procedure, each resident had been provided with a copy to inform them of their rights. All of the residents spoken with said they had confidence in the homes manager, and the staff at the home, to listen to any concerns and take them seriously. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 6 The environment was very well maintained in the majority of areas. The home was very clean and free from odours. Homely touches were provided in communal areas to create a comfortable environment. Residents were able to bring personal possessions with them into the home. All of the residents spoken with said the home was ‘lovely and comfortable’. One bathroom had been identified for refurbishment, and some kitchen cupboards required replacing. Agreed levels of staff were being maintained. The home had a commitment to National Vocational Qualifications (NVQ) to ensure staff had the skills needed to meet the needs of residents. Staff undertook a range of training and individual training records were kept. All of the residents and staff said the management at the home was supportive and approachable. Residents finances were safely managed, and insurance cover was in place. Health and safety systems were in place at the home, fire equipment had been checked and serviced. Staff had undertaken fire training at the required frequency to ensure they had the skills to maintain safety and respond in an emergency. What has improved since the last inspection?
Care plans had been updated to include information on residents’ wishes regarding dying and death. A bathroom had been identified within the homes decoration plan for refurbishment. NVQ training for staff continued, in order to meet required targets. The manager had registered to undertake NVQ level 4 in management and care. Records of monitoring visits, undertaken by a representative external to the home, had been updated to contain more detail. Staff mandatory training had been audited and refresher training in moving and handling, and food hygiene, had been provided. A written risk assessment regarding the use of footplates had been undertaken for an identified resident. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 7 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. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 8 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.V254777.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 and 5. Each resident had been provided with a contract. Trial visits to the home were encouraged to enable prospective residents to look around the home, meet other residents and staff. Staff undertook periodic training to keep them up to date and access to specialist services was provided by the home, in order that all needs were met. EVIDENCE: A copy of the homes contract was examined. This contained all of the required information for residents, and included details of the fee charged and the rights and obligations of the home and resident. The resident or their representative signed their contracts. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 10 All of the residents spoken with felt the home met their needs. One resident said ‘I couldn’t be better looked after’, and a further resident said ‘the home is wonderful, I can’t think of anything else I need’. Access to relevant specialists was supported by the home. The residents spoken with confirmed that they had been able to look around the home, stay for a meal and meet residents and staff to provide them with the information they needed before choosing to move in. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. Each resident had a care plan, to give staff the information needed to ensure all care needs were met. Health care was monitored, assessed and met. Medication was safely stored and managed. A controlled drugs register was required to ensure all safety procedures were correctly followed. Staff respected residents privacy and appeared respectful towards residents. Each care plan contained a section on ‘End of Life’ care, to ensure residents wishes were sought and carried out. EVIDENCE: Care plans contained the full range of information required. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. The residents had signed their plans. Residents spoken with were aware of their right to access their records, but chose not to do so. The plans contained detail of all health care contacts, appointments and treatments, and the home supported access to these to ensure health was maintained. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 12 A policy on medication was in place. All staff that administered medication had undertaken training to ensure that they had the required skills to maintain safety. Medication was stored securely. Medication administration records were accurate, up to date and corresponded with the medicines held. The home had appropriate storage for controlled drugs, but a controlled drugs register, to ensure the administration records were maintained safely, was not in operation. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Staff took time to sit and listen to residents. All of the staff displayed a high level of commitment to the residents and the home. Residents spoken to made very positive comments about their care. Resident told the inspector `I can’t think of how I could be better cared for’, `the staff are good, we can laugh together’. A professional visitor spoken with said they were `very happy’ with the care provided at the home. They told the inspector that they were kept well informed by the home, and had no concerns. Care plans were in the process of being updated to include information on end of life care. Those sampled contained this information. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 Residents were able to make choices about how they spent their time. The home had an open visiting policy, in order to develop and maintain good relationships with residents’ representatives. The home provided a varied menu and choices were offered to respect personal preferences. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to walk freely around the home. Residents confirmed that they were able to see their visitors in private, and they could visit the home as often as they chose. Visitors were always able to stay for a meal with their relative. Residents were able to bring personal items with them into the home. All of the residents spoken with said the food at the home was very good, choices were offered on a daily basis. One resident said that `I was asked when I came to the home what food I don’t like, the cook never forgets’. A further resident informed the inspector that they had their mid-day meal cooked in a different way to the menu, to respect their preferences. The manager ensures that residents food preferences are respected and purchase different bread and other sundry items according to individual liking. Staff confirmed that they had access to food supplies at all times, to cater for residents needs. The homes dining room was attractively set out.
Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home had a clear and accessible complaints procedure, to ensure residents’ rights were protected and any concerns listened to and taken seriously. EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the managers and staff to`sort out’ any worries if they had them. No complaints had been received by the home. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 and 21 The majority of the home was maintained to a very high standard. The home was very clean and free from odours. The building complied with the requirements of the fire service. Appropriate facilities were provided to meet residents needs. All areas of the home were accessible to residents. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained. Some refurbishment was required in the homes kitchen and bathroom. EVIDENCE: The home was decorated to a high standard. Communal areas were attractive, comfortable and the furniture provided was of a good standard. The home had a pleasant conservatory, and a large patio area had been built and garden seating provided for residents enjoyment. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 16 Twenty-one of the bedrooms had en-suite toilet facilities, 17 rooms had ensuite toilet and shower facilities. The home had a communal bathroom in addition to these facilities. Whilst the room was well decorated, the bath panel was damaged. The bathroom had been identified for refurbishment within the homes redecoration plan. All of the residents said that they were very happy with the accommodation provided. The homes kitchen had been partially refurbished. However, some cupboards were ill fitting or had drawer fronts missing. These must be replaced to maintain the high standards in the home. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Agreed levels of staff were being maintained. Some staff undertook NVQ training. Recommended levels of NVQ trained staff had almost been achieved. Staff undertook periodic training to keep them up to date. The home had a training plan and individual records were kept to monitor staff training. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of residents. Residents and the visitor spoken with felt that enough staff were provided. Of the 23 care staff, 7 staff had achieved NVQ level 2 in care and a further 2 staff were undertaking the award. This did not quite meet the recommended 50 of the care staff trained to NVQ level 2 in care by 2005, to ensure the staff team was qualified and competent to carry out their duties. However, the home had recruited a member of care staff who was also a qualified NVQ assessor, which will support further staff undertaking the award. Staff recruitment files were sampled. They contained all of the required information and included proof of identity, CRB checks, and two written references. The manager confirmed that CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks had been completed for all staff. Since the last inspection the homes recruitment forms had been updated to include evidence that gaps in employment history had been explored.
Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 18 Staff training records were maintained to ensure all staff had undertaken relevant training. Staff spoken to said that they received sufficient training to be able to carry out their duties. Since the last inspection, training in moving and handling and food hygiene had been provided to staff to ensure they were kept up to date with relevant skills. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,37 and 38. The manager’s leadership approach benefited residents and staff. The home had a quality assurance system in place, to seek the views of residents and their representatives. Business records were kept and insurance cover was in place. Residents’ monies were handled safely. The homes records were stored securely, to respect residents’ rights. Policies and procedures for the smooth running of the home and care of residents were in place and accessible to staff. Staff undertook mandatory training. Fire systems were checked and serviced. All staff had undertaken fire training at the required frequency. No staff were trained in first aid. EVIDENCE: All of the residents and staff spoken with said the managers at the home were approachable and supportive. The manager had registered to commence NVQ level 4 in management and care.
Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 20 Provider reports, in line with Regulation 26, took place, had been updated to include more detail so that sufficient information had been sought to monitor all aspects of the home. Questionnaires to seek the views of residents were undertaken. Records in the home were securely stored to protect confidential information. The home had health and safety systems in place. On the day of the inspection no fire exits were blocked and hazardous substances were securely stored. All staff undertook mandatory training. All of the staff on duty confirmed that they were up to date with mandatory training. Records evidenced that food hygiene, infection control and moving and handling training had been provided to staff in recent months. Two residents were moved in a wheelchair without footplates in use. One individuals care plan was checked, it did not include a written risk assessment to evidence that this practice was in response to assessed need. The inspector acknowledges that some risk assessments were in place, however, care plans require auditing to ensure that all residents have a relevant risk assessment undertaken, if needed. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 21 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 X 3 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 4 2 X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 X 3 2 Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 22 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 2 3 4 5 Standard OP9 OP19 OP19 OP38 OP38 Regulation 13 23 23 13 13 Requirement A controlled drugs register must be provided. Plans to refurbish the bathroom must be undertaken. The damaged kitchen cupboards must be replaced. (Previous timescale of 31/08/05 not met) Sufficient staff must be trained in emergency first aid to provide a qualified person on each shift. Residents must not be moved in wheelchairs without footplates in place unless a written risk assessment has been undertaken. All care plans must be audited to ensure they contain this information. Timescale for action 01/12/05 31/03/06 01/01/06 01/01/06 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations 50 of the staff team must achieve NVQ level 2 in care by
DS0000002950.V254777.R01.S.doc Version 5.0 Page 23 Coumes Brook 2 OP31 2005. The manager must achieve NVQ level 4 in management by 2005. Coumes Brook DS0000002950.V254777.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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