Inspection on 04/05/05 for The Coppice

This inspection was carried out on 4th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Coppice 13/04/07

The Coppice 29/06/06

The Coppice 15/11/05

The Coppice 17/02/05

The Coppice 05/04/04

The Coppice 11/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Coppice 51 Wellington Road Altrincham Cheshire WA15 7RQ Lead Inspector Helen Dempster Unannounced 4 May 2005 14:00 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Coppice Address 51 Wellington Road Altrincham Cheshire WA15 7RQ 0161 929 4178 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Elizabeth Fitzroy Support Responsible Individual - Mr Neil S J Taggart PC Care home only 7 1 6 Category(ies) of LD(E) Learning dis - over 65 registration, with number LD Learning disability of places The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One named individual currently accommodated has a learning disability and is also over pensionable age. Date of last inspection 17 February 2005 Brief Description of the Service: The Coppice is a detached brick built property and is in keeping with others in the road. The home provides accommodation with personal care for 7 people with a learning disability. It is situated near to a local school and there are traffic calming measures in the area. The house is divided into two properties with an inter-connecting door. The main body of the house provides accommodation for five residents. There is a semi-independent living arrangement for two male residents in the annex. There are large secluded rear gardens and parking. The laundry facilities for the home are situated in the detached garage at the rear of the property. The home has its own minibus, which affords the residents access to day care, local colleges, recreational facilities, and places of interest. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection (though the service was given 24 hours notice that the inspection was going to take place, to ensure that the manager was present during the inspection). The inspection took place over the course of two days, 4 and 5 May 2005. On the first day of inspection, the manager had difficulty in providing evidence to show that work had been done to meet requirements made at the previous inspection. At times, he seemed to find the inspection difficult and the inspectors felt that he would benefit from support from the organisation. The Registered Individual decided to send a senior manager to help him on the second day of inspection. During the inspection, time was spent talking to the manager, a senior manager from the organisation, all the people staying at the home and members of the staff team, to find out their views of the service. Time was also spent examining records, people’s files and other documents. As this inspection focused on specific standards and issues that were raised during the previous inspection in February 2005, this report should be read together with the previous and future reports to gain a full picture of how the service is meeting the needs of the people staying there. What the service does well: Staff used the home’s minibus to support residents to go out on activities in the community. At the time of inspection, three of the residents were about to be supported to the polling station to vote in the general election. It was a strength of the home that residents were encouraged to have their rights of citizenship and take as a full a life as possible in the local community. Some residents continued to go to the organisation’s day care service where they said they had many friends. One resident was talking about being excited about going on holiday soon with one of his friends from the day centre. Residents were able to have their rooms as they wanted them. Two of the residents invited the inspector to see their rooms, which had been personalised to reflect their love of football. . . What has improved since the last inspection? Since the last inspection, the home had given each resident a contract which included the terms and conditions of their residency. The home had also reviewed files so that confidential information about each resident was only The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 6 held on their own personal file, and not in files which contained information about other people. The home had also changed the complaints procedure so that it was easy to understand and made some improvements to staff files. Some things had also been done to make the home a safer place. These included completing fire safety checks each week and improving security arrangements at the home. What they could do better: Some of the things that the home could do better had already been explained to them in the last inspection report of February 2005. However, these things had not been put right and that was worrying. The things that were wrong were mostly about the management of the home and the way that information was given to people and written down in records. The service users guide, which gives information about the home to residents and their families, was out of date and was not freely available to people. Staff had not written down important information about residents, which helped people to know how to care for them in the way they chose and wanted to be cared for. This included a needs assessment for each resident, a care plan and risk assessments (to minimise risks wherever possible, including in manual handling). Some things the home did and did not do could put residents at risk. In particular, there were many errors in the administration and recording of the administration of medication. The manager and staff were not all aware of how to promote the use of the complaints and adult protection systems in the home. This was a problem because it did not ensure the safety of residents from abuse, or ensure that residents’ worries and concerns would be listened to and taken seriously. The biggest problem was that staff talked about a lack of leadership and one resident said that staff argued among themselves. Tensions in the staff team and a lack of effective leadership were causing a poor atmosphere at the home and this meant that residents were not being fully supported by an effective staff team. The senior manager was visiting the home regularly, but was not doing enough careful checking of evidence to show how the home was running. There was no clear audit of staff training, so the staff team had not always received the training required to fully meet residents’ needs. Requirements were made about all these issues and CSCI will be visiting the home often to check that things are improving and that changes which are needed are done. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 7 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 Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2and 5 Misleading and out of date information was provided in the Service Users’ Guide. This, and the failure to complete a needs assessment for each resident, could reduce individual choice in the way the service is delivered. EVIDENCE: The statement of purpose had been revised on 8/03/05. It needed further minor revision to meet Standard 1. This included information about the age range of potential residents. A requirement was made accordingly. The service users’ guide was kept in the office and was not therefore assessable to service users. Concern was expressed that this document was out of date and was misleading. In particular, it referred to a previous manager and assistant manager and included information about the very positive views of residents and their families which was out of date and whose source and the date the views were expressed could not be evidenced at the home from a quality assurance survey or any other documented source. A requirement was made accordingly. The senior manager said that no quality assurance survey had been conducted in the months since he had been in post. On an action plan, in response to requirements made at the previous inspection, the organisation had indicated that the manager was aware of the organisation’s needs assessment document and how it related to standard 2. This was not the case during the first day of the inspection, when the manager had difficulty locating it and when he did locate it he was unfamiliar with it’s The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 10 content. On the second day of inspection, this document was discussed with the manager and the senior manager. It was stressed that the document was last revised in 1997 which predates the National Minimum Standards and that it had not been completed for any of the 7 residents to identify their needs. An immediate requirement was made to the effect that a needs assessment was completed for each service user by 9 May 2005. In response to a requirement made at the previous inspection, each resident had a statement of terms and conditions on their file. Where possible, the resident and their next of kin had signed these documents. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9 The service had failed to identify most of the residents’ assessed needs, personal goals, choices and the way they wanted their care to be delivered by staff in an individual care plan. The service had failed to provide meaningful risk assessments to minimise risks wherever possible, including in manual handling. The service could not show that it fully supported people to take managed risks as part of an independent lifestyle. EVIDENCE: At the previous inspection, a number of requirements were made concerning care planning, essential lifestyle plans, annual “OK” health checks and risk assessments. It was of grave concern that only one of these 10 requirements had been addressed, despite receiving an action plan from the organisation stating timescales in which they would be addressed. These timescales, including dates in March and April, had passed at the time of this inspection. The senior manager was questioned about this and the fact that he had completed monthly monitoring visits on behalf of the organisation, which suggested that this work had been completed or was well in progress. He The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 12 initially stated that the progress made on care planning was that a proforma for care plans had been developed. When evidence of progress could not be found he agreed that there was not sufficient progress. At the time of inspection, only one of the residents had a care plan, with the potential to put service users at risk and undermine their choice in how care is delivered. When talking to staff, they referred to work done on care plans. When it was pointed out that there was only one care plan on file, staff seemed confused. It was clarified that they were referring to the personal information file and daily records and that some staff were not sure about what care plans were. The senior manager stated that staff were not trained in completing essential life style plans, yet no action had been taken to address this. Individual resident’s files were disorganised with no consistency of information e.g. one file had a pen picture but others did not. There was no evidence to suggest that files were consistently monitored and updated. One example was that one resident’s file had a section on personal goals and aspirations, which was blank apart from a note to the effect that this information needed to be completed by 30/04/03. Detailed, informative daily routine sheets were held on one resident’s file but this good practice was not extended to all residents. The staff had started to complete “OK” Health Checks for residents but these needed to be fully completed. Risk assessments were in place on residents’ files. These risk assessments noted that “guidelines are in place, staff to be aware of guidelines and work to them”. These guidelines were not available on files. Through discussion, the manager stated that there were no guidelines, as they had not been written. The manager and senior manager were informed that this bad practice could put residents at risk and an immediate requirement was made. The manager was advised to review and monitor language used on residents’ files. One resident’s file stated that he was “bad tempered” when not understood. This negative language is disrespectful to the individual and a more appropriate and helpful term to describe the resident’s frustration must be sought. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 14 The service does offer the opportunities and support that people require to access appropriate social, leisure and community based activities, but these are not identified in individual plans of care. EVIDENCE: Overall, the service did offer the opportunities and support that people required to access appropriate social, leisure and community based activities and in general, this was a strength of the service. However, individual resident’s social, leisure and community based needs and activities were not identified or recorded in individual care plans. A requirement was made accordingly under Standard 6. Some residents continued to attend the organisation’s day care service and had the opportunity to be supported to access social and leisure activities either in the home or the community. Within the home people had access to the television and music. At the time of inspection, three of the residents were proudly holding their voting cards and were about to be supported to the polling station to vote in the general election. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 14 Two of the residents showed their rooms, which had been personalised to reflect their love of football, to the inspector. One resident was talking about being exited about his forthcoming holiday. Staff used the home’s minibus to support residents to access activities in the community. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The level of error in the administration and recording of the administration of medication put residents at risk. EVIDENCE: At the time of inspection, medication was being administered from a new monitored dosage system, which had been in place for 3 weeks. The manager said that staff had attended training, provided by the supplying pharmacist, prior to the introduction of the new system. Despite this, there were numerous examples of error, which could put residents at risk. This included not administering morning medication to a service user on one day and not providing an explanation for this on the medication administration record (MAR) or on this individual’s day-to-day record. On this particular day the resident, who had not taken the medication prescribed due to the individual having seizures, had 2 seizures. Concern was expressed about the dangers this practice could result in. On viewing medication stock, it was seen that medication was missing from the monitored dosage packs for 2 residents on a day at the end of the month. Neither the manager, nor staff, could offer an explanation for this and there was no explanation documented on the MAR. The manager said that he was unaware that these tablets were missing indicating a lack of communication and monitoring. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 16 There were numerous gaps in the records where it was not clear whether medication had been administered or not. In addition, the staff were not using the symbols provided on the system to provide an explanation for any deviation to the prescribing instructions. An immediate requirement and other requirements were made concerning these issues. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The lack of awareness of and failure to promote the use of the complaints and adult protection systems in the home did not ensure the safety of residents from abuse or ensure that residents’ worries and concerns would be listened to and taken seriously. EVIDENCE: The home’s complaints procedure had been revised in response to a requirement made at the previous inspection, but needed further revision to include the details of CSCI. A requirement was made accordingly. A record of complaints made was in place. One resident talked about being upset that staff were arguing and not liking a member of staff. The complaints record was viewed and these two complaints had been recorded. However, the resident’s complaint concerning ”the attitude of agency staff” did not include evidence of the investigation of this complaint, including statements from the resident and staff member. The recorded outcome was that “agency staff not booked again”. Concern was expressed about this poor practice and the dangers it may pose to residents as the specific behaviour or attitude of the staff member was not clarified because the complaint had not been fully investigated. Communication in the home of this matter was poor, as one member of staff was aware of the complaint but did not know that the home was not going to use this member of staff again. This member of staff said that she felt that the member of agency staff had been booked again. This practice is unacceptable and fails to protect residents. A copy of Trafford Council’s Protection of Adults From Abuse Policy was in a policy file. However, the manager stated that he had “not read it all” and that he felt that staff had not read it. Staff interviewed confirmed that they had not read this document. There was a lack of audit trail of staff training, so the The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 18 manager was unable to identify which staff had attended adult abuse awareness. Neither the senior manager, or manager, were aware that the council were providing staff training in the implementation of this policy. This practice could put residents at risk and a requirement was made accordingly. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 26 The premises are homely, comfortable and attractive and meet residents’ needs. Some aspects of security arrangements were impeding residents’ independent access. EVIDENCE: The premises were clean, well maintained and had no offensive odours. The requirement made at the previous inspection to fit restraints to windows which could put residents at risk had been actioned. An audit of the contents of each bedroom had commenced to meet individual choices, but the requirement made at the previous inspection was reiterated as this information had not been recorded on residents’ files. A review of security arrangements had taken place in response to a requirement made at the previous inspection. One resident had complained about staff locking doors. Therefore, the security arrangements needed further review so that residents’ access is not impeded. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34 and 36 Tensions in the staff team and a lack of effective leadership were having a negative impact on the atmosphere at the home and residents were not being fully supported by an effective team. The staff team had not consistently received the training required to fully meet residents’ individual and joint needs and a lack of a clear audit trail of staff training was impeding planning of training. EVIDENCE: At the previous inspection, requirements were made concerning staff reading new policies, redesigning staff rotas and auditing and adding information to staff files. These requirements had been actioned, apart from the fact that staff had not all read Trafford Council’s Protection of Adults From Abuse Policy. (See concerns, complaints and protection for details). The organisation had recently introduced a 6 week induction for new staff. This included mandatory training and would take place 3 times annually. The senior manager said that this would be used to train staff for whom there was no evidence of them attending mandatory training. Staff were aware of the introduction of this training resource and this good practice was commended. However, there was no clear audit of staff training and the manager was unable to demonstrate that a training planning procedure, based on a detailed knowledge of shortfalls in staff training was in place. Staff supervision had The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 21 developed since the previous inspection, but annual appraisals had not been completed and a requirement made at the previous inspection was reiterated accordingly. Through discussion with staff and from the expressed view of one resident, it was evident that staff were not working well as a team. During the inspection, one resident became upset when he said that staff were arguing with one another and that this should not happen in his home. Staff described tensions in the team with one expressing the view that the home was a lovely place to work but “a rot has set in for a long time”. Staff described a lack of leadership and this will be addressed in the next section of this report. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,42 and 43 A lack of effective leadership and management monitoring and control was resulting in tension and low staff morale with the potential to put residents at risk. EVIDENCE: At the previous inspection, the manager did not have appropriate knowledge and grasp of the contents of requirements previously made and action taken to address these. Requirements outstanding from the report of the announced inspection, which took place on 5 May 2004, were reiterated at this time. It was of grave concern that of the 28 requirements made at the previous inspection, only 10 had been actioned. Some of the remaining 18 requirements reiterated on this report remain outstanding from May 2004. CSCI has issued immediate requirements, with short timescales, to address the most urgent of these issues. Monitoring visits will be made to the home to closely monitor progress made to meet these requirements. Throughout this inspection, it was evident that a lack of leadership and management control could put residents at risk. The manager stated that he The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 23 meets with the senior manager (who was present on the second day of inspection) once every 2 weeks. The senior manager had also been completing monthly monitoring visits to the home, which generate a report to the Registered Individual for the organisation as required by Regulation 26 of the Care Homes Regulations. This level of monitoring had failed to ensure that outstanding requirements were met, despite producing an action plan to CSCI which indicated that requirements were being actioned. When asked for an explanation for this, the senior manager said that he hadn’t been as clear with the manager as to what he needs to do and “shares some responsibility” for that but that he also believed that the manager had done more. The senior manager also said that he had not fully understood the role of Regulation 26 visits or the timescales for requirements on inspection reports. Specific examples of poor management of staff were discussed. One such example was the manager writing a message to a resident’s keyworker across the resident’s blank care plan asking when the plan would be completed. This entry was made on 2nd April, yet this staff member’s supervision notes of 1st April make no reference to not completing care plans. The care plan remained blank at the time of inspection and the manager stated that he had not drawn the staff member’s attention to his message. When asked why he believed staff had not completed care plans, the manager stated that some were “resistant” and he talked about staff “not seeing it as their role” but that others were “willing” but “need training”. It was of concern that this situation had not been effectively managed, resulting in most residents not having care plans. One member of staff stated” We just want someone with some leadership to bring things together”. This staff member said that staff felt demoralised and wanted “things sorting out in the interests of service users”. The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 1 x x 3 Standard No 22 23 ENVIRONMENT Score 1 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 1 1 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x x x x Standard No 11 12 13 14 15 16 17 x x 3 3 x x x Standard No 31 32 33 34 35 36 Score 2 x 1 3 x 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Coppice Score x x 1 x Standard No 37 38 39 40 41 42 43 Score x 1 2 x x 1 1 CS0000005606.V222825.R01.doc Version 1.30 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1) Schedule 1 14(1) Schedule 3(1) (a) 15(1) Requirement The statement of purpose and service users guide must be further revised so that they include all the required aspects of standard 1 The needs assessment must be revised so that it incorporates all aspects of standard 2. A needs assessment must be in place for each of the 7 residents. The registered person should ensure that plans of care are drawn up for each individual resident, with the involvement of that individual resident. Care plans must be developed to include details of all aspects of needs as detailed in Standard 6. A clear link to the assessment of needs required by Standard 2 must be established. Risk assessments concerning risks specific to all aspects of the individual service user’s personal care should also be linked to the care plan. Risk assessments must include clearly documented guidelines for staff and must be in place for all 7 service users. Timescale for action 09/06/05 2. YA2 09/05/05 3. YA6 09/05/05 4. YA6 15(1) 09/06/05 5. YA6 15(1) 09/05/05 The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 26 6. YA6 15(1) Care plans must be further 09/06/05 developed to include details of specific mental health conditions and support provided by staff. This must include the procedures and protocols used by the home in the management of aggression and administering of ‘when required’(PRN) medication. Residents social, leisure and community based needs and activities must also be identified and recorded in individual care plans. Care plans must be reviewed on a regular basis, and a documented review of care must be undertaken every 6 months. Each service user must receive an “OK” Health Check consistently. . Essential life style plans must be further developed so that any limitations to the rights of service users are justified through a risk assessment process. Risk assessments must be completed concerning the service users’ participation in the day-to-day running of the home. Manual handling risk assessments must be consistently updated to reflect the specific handling requirements of individual service users and must specify the aids and equipment used by the service users and the manner in which staff must safely handle a service user. 09/06/05 7. YA6 15(1) 8. YA6 15(1) 09/06/05 9. YA7 15 09/06/05 10. YA8 16(2)(n) 09/06/05 11. YA9 13 09/06/05 The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 27 12. YA20 13 Patient leaflets, for the medication administered by the staff, must be obtained from the pharmacy. Stock records of medication, must be accurate Medication procedures must be reviewed so that a safe system of medication administration is consistently in place with a clear audit trail for all medication Any complaint made under the complaints procedure must be fully investigated. A detailed record, including statements etc, must be kept in the home of the investigation and outcome of formal and informal complaints and concerns raised by the residents and families. Staff must receive training in dealing with complaints and customer care. The Manager and staff must read and familiarise themselves with Trafford Local Authority’s Adult Abuse Procedure. The manager must complete an audit of which staff have attended the organisations abuse awareness training and provide training as appropriate. This training must include specific guidance in the implementation of Trafford Local Authority’s Adult Abuse Procedure. The contents of all the bedrooms must be audited against the requirements of standard 26 and any shortfalls noted on the individual’s personal plan. An audit of staff training must be completed and consistently reviewed to ensure that staff are able to meet residents individual and joint needs. 20/05/05 13. 14. YA20 YA20 13 13 20/05/05 11/05/05 15. YA22 22(2)(3) and 18 11/05/05 16. 17. YA22 YA23 22(2)(3) and 18 13 20/06/05 11/05/05 18. YA23 13 20/06/05 19. YA26 16(2) 09/06/05 20. YA35 18 09/06/05 The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 28 21. YA36 18 22. YA38 18 and 24 23. YA39 24 The registered person should ensure that staff receive the support and supervision to carry out their jobs. This must include at least 6 supervisions per year and an annual appraisal. Management arrangements at the home must be reviewed and monitored to ensure that CSCI requirements are met within timescales. Management procedure and protocols must be reviewed to ensure that staff are supported in their role of caring for service users, including the preparation of needs assessments and care plans. Quality assurance systems in the home should be reviewed and updated so that the existing quality assurance manual is put into practice. This should incorporate service user satisfaction questionnaires, and the views of family, friends and advocates and stakeholders within the community on how the home is achieving goals for the service users. Health and safety procedures must be reviewed to include:-· Completing fire drills consistently and ensuring that records provide any details of the service users’ involvement, the type of drill, the staff and service users response and the time taken. All these points must be covered in a practice drill. The organisation must review the method by which Regulation 26 visits are conducted. These visits must be evidence based and give a clear and accurate account of the running of the home and health and welfare of residents. 09/06/05 09/06/05 20/06/05 24. YA42 23 20/05/05 25. YA43 26 20/05/05 The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 29 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 Good Practice Recommendations The Coppice CS0000005606.V222825.R01.doc Version 1.30 Page 30 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 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. 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