CARE HOMES FOR OLDER PEOPLE
The Coombs Sparrow Hill Coleford Glos GL16 8QE Lead Inspector
:Mrs Eleanor Fox Unannounced Inspection 09:50 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 The Coombs DS0000064579.V266924.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. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Coombs Address Sparrow Hill Coleford Glos GL16 8QE 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) 01594 833200 01594 837615 The Orders of St John Care Trust Mrs Gillian Shaw Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: The Coombs provides accommodation for up to 40 service users who require nursing and personal care. It is an attractive property, situated within its own spacious private grounds. It lies within easy reach of the town of Coleford. The Coombs comprises of a main house, a listed property, where accommodation for up to 16 service users is provided on two floors, accessed by a shaft lift; plus 3 additional small lodges, known as Holly, Oak and Beech, in which there is accommodation for a further 24 service users, 8 in each unit. All areas of the Home are pleasantly furnished and well maintained. A selection of comfortable communal facilities is also provided. The extensive beautifully maintained gardens are easily accessible and may be enjoyed by the service users in the summer months. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection over a period of 5.5 hours. It consisted of a tour of the property; inspection of a selection of written care records; recruitment files and other available documents; plus discussions with the Manager and 5 members of staff working in the Home. The service of the lunchtime meal to the residents was also observed. The inspector had the opportunity to talk to eight of the residents who were in the Home during her visit. She also spoke with three visitors who were in the home on this day She made a random selection of six residents, looking closely at their care files and medication documentation, and then visited their bedrooms and looked at various aspects of their daily lives during her inspection. What the service does well: What has improved since the last inspection?
Although no requirements were identified at the previous inspection, it was observed that there have been ongoing decorative and maintenance improvements undertaken throughout the property. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 7 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 The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 8 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): 3 and 5 A thorough assessment process plus the provision of detailed information and an invitation to visit the premises enables prospective residents to make an informed decision regarding their admission and gives them assurance that their needs will be met. EVIDENCE: A senior nurse, usually the Manager, undertakes a thorough assessment of each prospective resident before anyone is admitted to the Coombs. The findings are recorded and maintained on file to assist with eventual admission processes. There is already a long waiting list for available beds and so the Manager does not normally undertake the assessment until a room has been vacated. Where appropriate, information about the identified care needs is also provided from the allocated social worker. If possible, the prospective resident and/or a close relative is invited to visit the Home prior to admission to meet the other residents, the staff and to see all the facilities. One couple were shown around the home on this day as they were looking for suitable accommodation for an elderly gentleman. They were
The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 9 given a tour of the establishment and staff were available to answer any questions. One lady had recently been admitted to the home after a spell in hospital; she has already settled in well and said that she is very happy at the Coombs. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 10 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 and 9 Clear consistent care planning is in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. Medication systems, however, do require some minor improvements to ensure that residents are not put at any risk of potential errors. EVIDENCE: The care records relating to five selected residents were read on this visit to the Coombs. The Home continues to provide well considered care plans for each person, based on a thorough assessment of care needs. Appropriate risk assessments are also prepared as required. In addition to the routine reviews of care needs, the Home has introduced a new system to completely review all areas of care for each resident. This is discussed during a meeting with the resident, care staff, and usually includes a close relative or advocate, on a 6 monthly basis. The first few of these reviews have already been conducted, with positive results. It was observed that the resident or family member signs the reviewed care plans at this meeting. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 11 The provision of medications has recently been switched to a new supplier. Despite some initial ‘teething problems’, the staff at the Home are now adapting to the new processes. Medications are ordered and stored correctly. The medication records relating to the five selected residents were read in detail. It appeared that drugs had been administered as prescribed for each person. Where known allergies have been identified in the care plans, these have not always been correctly identified on the medication sheets although these omissions were promptly addressed. There were three examples where the person making the record had not signed handwritten entries on the drug administration sheets. Also any instructions should be written clearly, using English terminology. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 12 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): 14 The consideration and respect that is shown by staff towards residents ensures that residents are able to exercise control and choice in their daily lives. EVIDENCE: Where possible residents do handle their own financial affairs as long as they are able, however many of the current service users now require assistance in these matters. The Home has ascertained each person’s status in relation to Power of Attorney and the administrator keeps records of any monies retained for the residents; these were not checked on this visit. Residents are free to personalise their rooms with some small items of their own furniture and personal belongings. One lady was most keen to show off the Christmas decorations in her area of the Home; she clearly felt ‘at home’ at the Coombs. A visitor also commented on how well her friend had settled into the Home, commenting that, “she enjoyed relating details about any special events, which had been arranged there. She belongs here now”. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 13 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 A satisfactory complaints system enables service users and their families to feel assured that their views would be listened to and acted upon. EVIDENCE: There have been no formal complaints received in the Home since the last inspection. The clearly detailed complaints policy is contained in the Statement of Purpose folder, kept on a table beside the front entrance and readily available to residents, their visitors and staff working at the Home. This information was also seen displayed on a notice board. One person did confirm that if she had any worries, she normally spoke first to her carer (her key worker) who always “sorted things out”. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 14 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 A safe and well maintained environment continues to provide residents with a good standard of comfortable accommodation. EVIDENCE: The majority of the home is maintained and decorated to an acceptable standard. The whole property was comfortably warm, clean and fresh. The handyman is responsible for addressing any ongoing decorative requirements in the property. He also maintains the gardens in a most attractive state. Some of the residents were sitting in one of the small lounges watching the birds pecking on a bird table just outside they window; two people were deriving considerable enjoyment from this activity. It was reported that a new assisted bath would be provided for the Coombs next Spring. The Fire Alarm systems are also going to be upgraded. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 15 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): 28, 29 and 30 Residents receive care from a stable competent workforce but improved recruitment practice would help to ensure residents are fully protected. EVIDENCE: Ten out of the twenty-seven carers employed at the Coombs have already completed a National Vocational Qualification, level 2 in care. Three of these are now studying for a level 3 Qualification. Five additional carers are about to commence their studies for the level 2 qualification. The personnel records relating to all four members of staff employed since May 2005 were seen on this visit. Careful recruitment procedures are normally followed when employing new members of staff at the Home. All the required criminal record screening is undertaken before the member of staff joins the team but information about their full employment history plus the reasons for any gaps in employment is not yet obtained in every case; the application form only requests details of the previous ten years and even this had not been completed fully in one example. Full written records are maintained of the interview processes. Each new member of staff is fully inducted to their roles and responsibilities. The Deputy Manager takes responsibility for coordinating training in the home. This is arranged in an organised fashion with clear records maintained, ensuring that each person attends any mandatory training within acceptable
The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 16 timescales. Details of available training courses are advertised on the staff notice board. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 17 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): 33, 37 and 38 There is a thorough programme of self-review and consultations in place at the Home; some additional details are required to ensure that residents gain full benefit from these processes. There are also good management systems in place to ensure that the health and safety of the residents is safeguarded; the need for one small improvement has been identified. EVIDENCE: The home does have a good focus on quality improvement. There is a notice in the front hall indicating that the staff are, “committed to improving the service”. Forms are left readily available for residents and visitors to complete if they have any suggestions or feedback about the Home to share. Medication administration, care planning documentation, any complaints, accidents or adverse incidents, and satisfaction with the provision of food are
The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 18 all monitored closely. The home was also about to undergo an external quality audit. However, a quality improvement report has not been provided for the Home in the last twelve months, as is required. All the records seen on this occasion were maintained correctly and stored securely. It was confirmed that residents might have access to this documentation if they wish. The details are shared with the residents during the six-month review meetings. Health and safety issues are generally addressed well at this Home. However, it was observed that, although there was a notice on the door of one bedroom to warn people that Oxygen therapy was being provided, there was no advice of the precautions to take in the vicinity of this area; for example not to smoke or to strike a match. This is now being provided. Members of staff do have good fire safety training and one person who was questioned was well aware of her duties if the alarm sounded. The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 19 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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x x STAFFING Standard No Score 27 x 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x 3 2 The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement Timescale for action 31/12/05 2 OP9 13(2) 3 OP29 Sch. 2 The person making the record in the drug administration documentation must sign any handwritten amendments. All instructions for administration must be in clear English. Staff must ensure that 31/01/06 appropriate information, including if ‘none known’, is recorded in the ‘Allergy information’ boxes on medication charts. Each prospective employee must 31/12/05 provide a full employment history plus a satisfactory explanation for any gaps in employment. A quality improvement report must be provided for the home Adequate warning instructions must be clearly displayed when oxygen is being administered to a resident 28/02/06 31/12/05 4 5 OP33 OP38 24(2) 13(4) & 23(4) The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Coombs DS0000064579.V266924.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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