Care Home: Coppice Wood Lodge

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What the care home does well The home provides consistently good outcomes for people. We found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The home provides a statement of purpose that is specific to the home and the resident group that they care for. The statement of purpose confirmed that the cultural and religious needs of people would be respected. People are supported to maintain their cultural and religious identity. Admissions are not made to the home until a full needs assessment has been undertaken to ensure the best outcomes for people. Care plans make sure that people`s needs are addressed in a person centred way. Detailed nutritional, tissue viability, falls and manual handling assessments have been put in place. Management of risk ensures that safety issues are addressed whilst at the same time improving the quality of life for people living at the home. People spoken to told us that activities are provided regularly. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. There were policies on handling abuse and protection. People feel safe and well supported by the home, which has their protection and safety as a priority. The home has the necessary adaptations to support people to move around safely. The home provides an accessible and safe environment for people to live in. Bedrooms were personalised with items of furniture and pictures belonging to the people who live at the home. People are encouraged and supported to personalise their bedrooms. The rota showed that a consistent staffing level was being maintained in the home. There is consistently enough staff available to meet the needs of people living at the home. People spoken to felt that staff had the necessary skills to meet their needs. Staff are supported through training to meet the individual needs of people. The registered manager has extensive experience of managing a service for older people. The registered manager has a clear understanding of how to deliver good outcomes for people living at the home. We discussed health and safety issues with staff and they demonstrated their understanding. Health and safety checks, procedures and training make sure that people living in the home are safe. What has improved since the last inspection? No areas for improvement identified at the last inspection. CARE HOMES FOR OLDER PEOPLE Coppice Wood Lodge 10 Grove Road London N11 1LX Lead Inspector Tony Brennan Unannounced Inspection 22nd May 2008 09:30 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 Coppice Wood Lodge DS0000030826.V364537.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. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coppice Wood Lodge Address 10 Grove Road London N11 1LX 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) 020 8366 6565 www.enfield.gov.uk London Borough of Enfield Mrs Catherine Gallagher Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2007 Brief Description of the Service: Coppice Wood Lodge is a purpose built local authority care home. The home is owned and managed by the London Borough of Enfield and is located within approximately five minutes walking distance from the Arnos Grove Underground on the Piccadilly line. Bus stops and local shops are also within a short walking distance from the home. The home is registered for up to fortyfour older people who may have dementia. However, as part of a plan to make all bedrooms single occupancy, currently the home can accommodate thirtyseven people. The home is a two-storey property with a lift to all floors. Coppice Wood Lodge is divided into four units; each with a number of bedrooms linked to a lounge. One unit is on the ground floor and the other 3 are on the first floor. Two care staff are assigned to each of the units during late and early shifts. Three waking night staff and a sleeping-in senior member of staff covers the night shifts. There are a number of bathrooms, toilets and washing facilities throughout the home. The home is accessible for people with mobility difficulties. The homes most recent inspection is available on the homes notice board and the manager has agreed to put a copy of the homes purpose and function document on display for relatives and service users. The fees for the home are £641.00 per week. Coppice Wood Lodge DS0000030826.V364537.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was undertaken as part of the annual inspection programme. Prior to the inspection the home had completed its Annual Quality Assurance Assessment. The Annual Quality Assurance Assessment provided us with information about the home and how it was seeking to provide the best outcomes for people. We also looked at any other information we had received about the home since the last inspection. This included any information regarding incidents that the home had told us about. The inspection took place over one day. We were assisted by Catherine Gallagher, the registered manager, with the inspection. We spoke with five people who live at the home, two relatives and five members of staff. We observed care practice and interaction between staff and people living at the home. We toured the building and examined a number of records relating to the care, health and safety and management of the home. At the end of the inspection feedback was given to the registered manager. We would like to thank the staff that assisted us by answering questions about the running of the home. We would also like to thank the people who live at the home who discussed their views of the service they receive. What the service does well: The home provides consistently good outcomes for people. We found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The home provides a statement of purpose that is specific to the home and the resident group that they care for. The statement of purpose confirmed that the cultural and religious needs of people would be respected. People are supported to maintain their cultural and religious identity. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 6 Admissions are not made to the home until a full needs assessment has been undertaken to ensure the best outcomes for people. Care plans make sure that people’s needs are addressed in a person centred way. Detailed nutritional, tissue viability, falls and manual handling assessments have been put in place. Management of risk ensures that safety issues are addressed whilst at the same time improving the quality of life for people living at the home. People spoken to told us that activities are provided regularly. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. There were policies on handling abuse and protection. People feel safe and well supported by the home, which has their protection and safety as a priority. The home has the necessary adaptations to support people to move around safely. The home provides an accessible and safe environment for people to live in. Bedrooms were personalised with items of furniture and pictures belonging to the people who live at the home. People are encouraged and supported to personalise their bedrooms. The rota showed that a consistent staffing level was being maintained in the home. There is consistently enough staff available to meet the needs of people living at the home. People spoken to felt that staff had the necessary skills to meet their needs. Staff are supported through training to meet the individual needs of people. The registered manager has extensive experience of managing a service for older people. The registered manager has a clear understanding of how to deliver good outcomes for people living at the home. We discussed health and safety issues with staff and they demonstrated their understanding. Health and safety checks, procedures and training make sure that people living in the home are safe. What has improved since the last inspection? Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 7 No areas for improvement identified at the last inspection. 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. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 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 Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 13 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose is an accurate description of the service provided. People’s needs are assessed prior to admission to the home to ensure they receive the care and support they need. EVIDENCE: We found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The annual quality assurance assessment stated that the home has a comprehensive statement of purpose. The statement of purpose also identified the skills and staffing resources available to meet the needs of people. Staff spoken to were able to explain in Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 10 detail how they met the needs of people who have dementia. Training record show that the majority of staff had completed a national vocational qualification and training on meeting the needs of people with dementia. The home provides a statement of purpose that is specific to the home and the resident group that they care for. The statement of purpose confirmed that the cultural and religious needs of people would be respected. Records show that people were supported by the home to maintain contact with their church or other community groups. We spoke with the registered manager told us that cultural and religious needs would be addressed and identified through initial assessments and care planning. One person said, “I take part in a weekly service.” The registered manager confirmed to us that if people wish to attend places of worship staff would accompany them. People are supported to maintain their cultural and religious identity. People living at the home have varying degrees of disability. The environment has been adapted so that it is accessible. One of the people case tracked said, “ The home could not be better.” We observed that people were able to move about the home safely. People had their photograph on their bedroom doors to help them identify their bedrooms. The homes environment is adapted to meet peoples diverse needs. A person who lives at the home said, “ staff here understand my needs. They look after me well.” The annual quality assurance assessment stated that there were comprehensive pre admission assessments in place. Currently the home is not admitting people permanently although respite admissions are still taking place. All people case tracked had been reviewed by a social worker in the last year. There had been two recent admissions to the respite unit. We found that when we case tracked these two people that they had detailed initial assessments from their social workers. These had recently been prepared. The initial assessments of these two people identified the areas where they needed support. One of the people case tracked has dementia and may occasionally leave the building unaccompanied putting their safety at risk. This was identified in the person’s care plan. Staff spoken to were aware of this and how to respond to the person’s needs. Detailed initial assessments are carried out with the involvement of people to make sure they needs are identified. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal, social and medical care needs are fully planned for. People who use the service are fully protected by safe procedures for handling medication. Peoples right to privacy is supported. EVIDENCE: We found that the care plans of all the people case tracked were detailed and clearly identified how the needs of people would be met. Care plans were based on initial assessments of the people case tracked. There were clearly defined actions highlighted in the care plans to meet the needs of people. We found that people’s choices and preferences are recorded in their care plans. The care plan of one of the people case tracked told staff that she preferred Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 12 hold her own medication and do her own personal care. We spoke with this person who said, “ staff understand me and how I want to do things for myself.” The care plans for the people case tracked were found to reflect their choices and preferences. People commented that they had been asked about how they wish to be supported by staff. Staff were observed to interact respectfully and sensitively with people living at the home. People said that staff respected their privacy and treated them with respect. People we spoke to told us that they felt staff understood their needs. A key worker the system is in place. We observed that staff spent time talking with people. Key workers involve people in the care planning process. Care plans were personalised, and referred to the cultural needs of people. This included whether or not they wish to take part in religious services. There were also personal histories that provided information on peoples interests and previous occupations. People are involved in the planning of their care that affects their lifestyle and quality of life. Detailed nutritional, tissue viability, falls and manual handling assessments are in place. The people case tracked all had nutritional assessments. People were being weighed regularly and action taken if their weight changed. The continence needs of people had been assessed and recorded as part of their care plans. Each care plan includes a manual handling risk assessment. Equipment had been provided to assist people to mobilise safely and independently. Management of risk ensures that safety issues are addressed whilst at the same time improving the quality of life for people living at the home. Diary notes showed that appropriate medical attention and advice is sought. Diary notes also confirmed that the people case tracked had access to their General Practitioner when necessary. Another person told us, “The doctor always visits regularly.” A person who had recently come to stay at the home confirmed that she was able to, “ keep the same general practitioner as I have at home.” Where the General Practitioner had recommended specific medical interventions these were followed up. One person case tracked has been prescribed Warffin. This is being monitored regularly. The district nurses do regular blood tests and this was recorded in the person’s daily notes. The general practitioner had recorded changes to the dose of this medication. People’s health is promoted to ensure their continued well being. The records of medicines received, administered and returned to the pharmacist were all complete. We were able to confirm that people were getting their medication as prescribed by their general practitioners. We found where the General Practitioner had made changes to peoples medication this was signed to confirm the change had been made. We found that the medication for each of the people case tracked was accurately recorded. One of the people case tracked self-administers her medication. We found that a Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 13 risk assessment had been carried out to ensure this was done safely. The person had a lockable space in their bedroom to hold their medicines. The fact that they were self medicating was referred to in their care plan. All other people living at the home are supported by staff to take their medicines. The people we case tracked had their consent to staff administering their medication recorded in their care plans. One of the people case tracked did not have the capacity to make this decision. This was recorded in their care plan and the appropriate consultation had been carried out with their relatives and relevant professionals. Medication records are fully completed, contain the required entries, and are signed by appropriate staff to ensure peoples safety. Medicines were stored safely. All medicines are stored at the appropriate temperature. Separate records were maintained for controlled drugs. We found these were complete and the amount of medication held corresponded with those recorded in the controlled drugs book. The registered manager explained that she and the management team were currently completing a course on assessing staff competence in handling medication. The management team will be making sure that staff follows correct procedures when handling and administering medication. Regular management checks are carried out to make sure that medication is administered safely to people. Training has been provided on the safe administration of medicines. We spoke with staff and found they were clear about their responsibilities and how to handle medicines safely. Training records also contained certificates confirming that this training had taken place. We were able to observe staff administering medication, and confirmed that this was done safely. Staff understands how to administer medication safely to people living at the home. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 14 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): 12 13 14 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are provided with varied activities to meet their needs. People living at the home are supported to maintain contact with relatives and other representatives of their choice. The menu reflects the preferences of people living at the home and offers a balanced diet. EVIDENCE: We spoke with people who live at the home who told us that they are provided with regular activities. One person told us, “There are regular activities to do.” We observed that activities were taking place at various times throughout the day. A group discussion and a bingo session was held in the afternoon. People appeared to enjoy this. People spoken to told us that these activities are provided regularly. Peoples’ interests were recorded as part of their care plans. People are involved in Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 15 meaningful daytime activities of their own choice and according to their individual interests and capabilities. We observed that staff spend time talking with people who live at the home and listening to what they had to say. Staff spoken to understood the importance of one-to-one contact for people. One person said, “ Staff are friendly and spend time talking with me.” Relatives commented that there were no restrictions on visiting the home. People told us that they could see visitors in private if they wished. Diary notes showed that people had regular contacts with family, friends and the wider community. The menu showed that options are offered at each meal. The menu is varied offering a number of choices of meals. The cook explained that the menu is changed regularly. This is done to reflect seasonal variations, and with the involvement of people living at the home. We spoke with people who were generally pleased with the quality of the food provided. A person who lives at the home said, “ the food is very good. What I love is that they go out of their way to offer a very wide choice of meals ”. We observed that people are asked whether they preferred the first or second choice on the menu. Another person commented about the choice of food offered and that staff, “ do bring an alternative if whats on the menu is not to your taste.” people are offered a variety of meals that reflect their personal preferences and meet their dietary needs. Meals were balanced and nutritious. We observed that meals were well presented and they were provided in a relaxed manner. People were supported to eat. This was done at the pace of the people being assisted. Tables were laid out so that people could easily access condiments and napkins. People are able to enjoy the food they prefer and like. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 16 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): 16 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are confident that their complaints will be listened to, taken seriously and acted upon. The home’s procedures protect people from abuse. EVIDENCE: The annual quality assurance assessment confirmed that a clearly defined complaints policy with agreed timescales for managing complaints was in place for people to use. We found that the detailed policy was in place. People living at the home told us they had received a copy of the complaints policy. A person said, “ Ive got the complaints policy.” No complaints had been referred by the Commission to the home since the last key inspection. A complaints book is available to record all concerns, allegations and complaints. We found that the complaints book recorded the actions that had been taken to address issues. The complaints record showed actions taken to resolve complaints. People with whom we spoke confirmed that they knew how to make a complaint. A person told us, “I can tell the manager or my relative if I had a complaint.” The home has an open culture that allows Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 17 people to express their views, and concerns in a safe and understanding environment. There were policies on handling abuse and protection. People living at the home felt confident that any concerns they raised would be handled sensitively and appropriately. A person told us, “ I can tell staff if I am worried about things.” There had been one adult protection issue since the last key inspection. This is still being investigated. The home is co-operating fully with this investigation. We found that in response to the issues raised by this allegation a number of improvements to the service had already been made. The registered manager explained that she has introduced the new system to make sure that up-to-date information is available to staff about the needs of people who come to the home on respite. New guidance has been issued regarding when medical attention should be sought for people having respite at the home. We found that staff had received training on adult protection. Staff spoken to could recognise the signs of potential abuse, and how they would respond to it. People feel safe and well supported by the home, which has their protection and safety as a priority. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 18 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): 19 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that provides a safe and homely environment. The home is clean and hygienic. EVIDENCE: We walked round the home and found that it was appropriately furnished. A passenger lift provided access for people to all floors. We observed that people were able to access all areas in the home safely. The home has the necessary adaptations to support people to move around safely. The home is appropriate measures are in place to assist people with dementia to orient themselves when walking around the home. There are large dining and sitting areas for Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 19 the use of people. The home provides an accessible and safe environment for people to live in. Bedrooms were highly personalised with items of furniture and pictures belonging to people. Bedrooms are decorated to a high standard. New items of furniture, curtains and bed linen had been bought for people’s bedrooms. One person said, “ the staff helped me to put my furniture in my room. It is very nice.” People had their photograph on their bedroom doors to help them identify their bedrooms. People are encouraged and supported to personalise their bedrooms. The maintenance records showed that ongoing maintenance issues are addressed. Any repairs are dealt with quickly to ensure the comfort and safety of people. The building and grounds have a rolling maintenance programme. A number of areas in the home had been decorated recently. New furniture had also been courteous for the communal areas. The registered manager explained new windows would be purchased for all bedrooms. The home is maintained to a high standard for the benefit of people. Appropriate measures are in place to prevent cross infection. The home has detailed policies on the prevention of cross infection. Staff have received training on infection control measures. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. Effective infection control measures are in place to ensure the safety of people living at the home. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 20 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): 27 28 29 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Sufficient staff are available at all times to meet the needs of people who live at the home. Staff do have all the skills to meet all the assessed needs of people who live at the home. People who live at the home are protected by the home’s recruitment practices. EVIDENCE: The rota showed that a consistent staffing level was being maintained in the home. This confirmed that sufficient staff are available to meet the needs of people. Staff said that the current staffing level allowed them to meet the needs of people. Until recently there was a freeze on recruitment while decisions were made about the long-term future of the home. The registered manager explained that to make sure that sufficient staff were available a pool of agency staff was used. These staff have been working in the home regularly. Staffing levels have remained consistent and peoples needs have been met. The registered manager explained that a recruitment drive has now Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 21 started an advert has been placed for care staff. People living at the home told us that staff are available to meet their needs. We observed that staff were available at key times of the day (e.g. mealtimes) to assist people. Staff were also observed to spend time with people both individually and in small groups. Also staff went for a walk with people. This allowed more attention to the individual needs of people. There is consistently enough staff available to meet the needs of people living at the home. The annual quality assurance assessment highlighted that staff had been on a range of courses. People spoken to felt that staff had the necessary skills to meet their needs. One person said, “ Staff really do care. They understand my needs.” Training records showed that staff had been on a range of courses relating to the needs of people who live at the home. We found that these included training on dementia. Staff and been on an advanced dementia course. There were certificates available to confirm this. Also there had been training on person centred care. Staff are supported through training to meet the individual needs of people who live in the home. The annual quality assurance assessment showed that at present 99 of staff have achieved the National Vocational Qualification in care. The home has managed to maintain this consistently. Staff spoken to confirmed that they had all the areas of required training. Training records also confirmed this. The registered manager has made all training available to agency staff working at the home. Agency staff spoken to told us they felt supported. They could also demonstrate that they understood and knew how to meet the needs of people who live at the home. The home ensures that all staff receives relevant training that is focused on delivering improved outcomes for people. Currently no new staff have been recruited to work at the home. Over the last three inspections it was found that approved recruitment procedures were followed. This included references, CRB checks and no unexplained gaps in the employment history of staff. Health checks had been carried out to ensure that staff were safe to work with people living at the Home. The registered manager explained that agency staff are also recruited using the same recruitment procedures. The home recognises the importance of effective recruitment procedures in the delivery of a quality service and to protect people. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 22 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): 31 33 35 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate management structures are in place to ensure that people receive the care they need. People who live at the home are consulted about the quality of the service, and encouraged to make suggestions for improvement. People who live at the home have their financial interests protected by the home’s procedures. People who live at the home and staff are protected by the home’s health and safety procedures. EVIDENCE: Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 23 The registered manager has extensive experience of managing a service for older people. The registered manager has maintained and updated her skills regularly. She has a clear understanding of the key principles and focus of the service to make sure that people receive the care they need. We observed that the registered manager spent time talking to people who live at the home. Any issues they raised with the registered manager were immediately addressed. The registered manager has a clear understanding of how to deliver good outcomes for people living at the home. The registered manager works to continuously improve the home and provide an increased quality of life for residents. She has completed a detailed annual quality assurance assessment and this provides a clear picture of how the service will be developed for the benefit of people living at the home. We have monitored monthly regulation 26 reports these show that the registered manager consistently addresses any issues where improvements may have been identified. The home has a system for obtaining the views of the quality of the service it provides. The home makes sure that any areas for improvement are addressed. A survey of the views of people who live at the home, relatives and professionals was in place. Minutes of meetings with relatives and people who live in the home were seen and these confirmed their involvement in the running of the home. The registered manager explained that relatives are involved through the friends of Coppice Wood in raising money for the home. People who live at the home have meetings on a regular basis to discuss how they wish the home to be run. Staff meetings take place to ensure staff are aware of plans to develop the service. People’s views are sought and provide the bases for improving the quality of the service. People and their representatives are consulted about the improvement of the service. The home does not hold money for people who live at the home. The home invoices their families or the relevant social service department for any expenditure made on their behalf. A system is in place to ensure receipts are obtained for any expenditure. People use the service trust the home to handle their money safely. The home has a consistent record of meeting the relevant health and safety requirements and closely monitors its own practice. Regulation the 26 visit reports showed that any health and safety issues were dealt with promptly to improve safety for people who live at the home and the staff. Fire drills were taking place and the fire alarm was tested regularly. We found that the fire risk assessment includes an assessment of all the potential fire risks in the home. We questioned staff on the fire safety procedures and found that they understood fire safety issues. All health and safety policies were available. Certificates for gas, legionella and electrical testing were in date. COSHH guidance was in place and chemicals were stored safely. We discussed Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 24 health and safety issues with staff and they demonstrated their understanding. The home has an effective system for monitoring accidents to ensure the safety of people who live and work at the home. The temperature of food delivered to and cooked was recorded. The temperatures of the fridges and freezers were recorded and within safe limits. Health and safety checks, procedures and training make sure that people living in the home are safe. Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 26 No 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. Standard Regulation Requirement Timescale for action 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 Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Coppice Wood Lodge DS0000030826.V364537.R01.S.doc Version 5.2 Page 28 - 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. 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