Inspection on 11/09/07 for Coopers Mill Ltd

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Pocklington House

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Coopers Mill Ltd Mill Road Walpole Highway Wisbech Cambs PE14 7QL Lead Inspector Lella Hudson Unannounced Inspection 11th September 2007 2:30 Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 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 Coopers Mill Ltd DS0000070041.V350700.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 Adults 18-65. 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. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coopers Mill Ltd Address Mill Road Walpole Highway Wisbech Cambs PE14 7QL 01945 880020 01945 880020 lordofcoopersmill@btinternet.com 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) Coopers Mill Ltd Mr Barry Lord Care Home 15 Category(ies) of Learning disability (13), Sensory impairment (2) registration, with number of places Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection This is the first Inspection of this Home since it has been registered as being owned by a company Brief Description of the Service: Coopers Mill is a converted farmhouse situated in the village of Walpole Highway, approximately 5 miles between Wisbech and Kings Lynn. Set on the edge of the village the Home is complemented by 5 acres of grounds that include large lawns and flower beds. Several animals are kept at the Home including ponies, rabbits and a dog. In 1995 an extension was built to the Home and a further extension was added in 1998. The accommodation consists of both ground and first floor single bedrooms in the main house, some of which are ensuite. There are several communal rooms including a large conservatory. One of the extensions provides accommodation for four clients who are able to live semi-independently but who also have access to the rest of the Home. The Home provides accommodation for up to fifteen adults with a learning disability. Two people with sensory disabilities may be accommodated and the annexe has additional equipment fitted to enable people with hearing loss to live there. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mr and Mrs Lord have owned the Home for many years. In 2007 the service had to be reregistered with the Commission as Mr and Mrs Lord had formed a limited company who are now the legal owners of the Home. As per the Care Standards Act this means that the service is considered to be a “new” service although the only aspect that has changed is the legal ownership. Mr and Mrs Lord remain the people responsible for all aspects of the management of the Home and are referred to as ‘the Proprietors” throughout this report. This Home was inspected in April 2007 and scored “excellent” for six of the eight groups of outcomes for the clients (service users). Reference to that report is made within this one due to the short timescales between Inspections. This Inspection found that the previously high standards have been maintained, and in some areas have been improved in the five months since the last Inspection. Seven of the outcome groups are now scored as “excellent”. This report includes information gathered about the service since it was registered and that gathered during an unannounced visit to the Home which was carried out between 2.30pm and 5.50pm on Tuesday 11th September 2007. It also contains information gathered from comment cards received from clients, relatives and health/social care professionals at the time of this visit and those received at the time of the visit in April 2007. During this visit the Inspector spoke to several of the clients and staff as well as to Mr and Mrs Lord. Examples of records were looked at and some of the communal areas of the Home were seen. All of the comment cards contain very positive comments about the Home with additional comments made such as: “staff are friendly, caring and supportive” (client) “I like everything about it” (client) “I cook my tea when I’m hungry” (client) “there is nothing bad about the Home” (client) “they always go the extra mile” (professional) “they are always willing to listen and act if necessary” (professional) “meets needs to exceptionally high standard” (professional) “could not ask for nicer place for … to be” (parent) “I don’t think that there could be a better place for … to live” (parent) Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 6 The Annual Quality Assurance Assessment (AQAA) was completed to a high standard and information from this is also included in this report. Currently the fees range from £384.00 to £1,836.00 per week and are individually negotiated, depending on the needs of the clients. What the service does well: What has improved since the last inspection? Since the Inspection in 2006: Two more bedrooms have got ensuites. The quality assurance process has been further developed and takes in the views of the clients, staff, relatives and professionals on a regular basis. More staff have received training with regard to the use of sign language. Since the Inspection in April 2007: The procedure relating to Safeguarding Adults has been reviewed and updated. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 7 The AQAA has been completed to a very high standard and provides a good annual review of the quality of the service. The small lounge has been redecorated and got new furnishings. One of the clients is now involved in administering their own medication. 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. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Thorough assessments are carried out prior to clients moving to the Home with the needs and wishes of the client being the highest priority during this process. EVIDENCE: The Proprietors ensure that prospective clients are central to the process of assessment and decision making about moving to the Home. Assessments are gathered from others involved in the clients life e.g. professionals and relatives. A lot of time is spent with the client themselves to find out what they feel is important to them about a new home. The clients are encouraged to visit the Home as many times as they feel they need to make a decision about moving there. The Home has printed information about the Home which is provided in alternative formats depending on the needs of the client. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 10 The AQAA identifies that the Proprietors intend to include questionnaires specifically about the admission process as part of their ongoing detailed quality assurance process. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The care planning and risk assessment process are based on the core belief that the clients should be supported to take control of their own lives and make their own decisions. EVIDENCE: The clients completed comment cards all state that they are aware of their care plan. Two of the clients proactively brought their care plans to show the Inspector during the visit to the Home and had clearly been part of the whole process of developing the care plan and understand the content. The care plans are detailed and contain assessments, risk assessments and evidence of regular reviews. They are produced in alternative formats using easy read language, photographs and pictures. The AQAA identifies that further development of alternative formats for the care plans is planned. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 12 Staff have a good understanding of the content of the care plans and of the need to involve the clients in ongoing reviews and monitoring of the plans. A letter from a health/social care professional was seen by the Inspector in which the care plans were highly praised. Additional comments on the comment cards received from health/social care professionals include the following: “there are good care plans which are updated and used” “…really does try to respond to the needs of individual clients” “there are good discussions about care plan objectives” All of the staff attend communication training and two of the staff have attended basic British Sign Language training which they are passing on to the other staff. The staff team understand the importance of developing alternative forms of communication for those with communication difficulties so that they are able to make their own decisions and contribute to the ongoing discussions about the development of the Home. The focus of the care plans is to ensure that all staff are aware of the clients needs and choices and to ensure that these are respected and met in a consistent way. The care plans contain information about behaviours which staff and other clients may find challenging. Detailed information is included about the known triggers for these behaviours and how steps should be taken to reduce the triggers if possible. There is an understanding that behaviour is a form of communication. Management of risks is a balance of encouraging and promoting individual clients choices with a responsibility to maintain their safety. Clients gave examples of situations affecting them which are covered by risk assessments. Discussions with clients provided lots of examples of how they are encouraged and supported to make their own decisions about a range of issues affecting their lives. The staff also provided many examples of how they provide the support to the clients to enable them to develop their independence. Through the care planning and person centred approach that is in place at the Home several clients have decided that they would like to move on to a more independent style of living and the Proprietors and staff are supporting them with these decisions. The Proprietors have supported the involvement of advocates in this process. The staff said that during their induction it is made clear that the needs of the clients are the focus of the Home and that the routines of the Home are organised around these. The Proprietors are clear about their role being to encourage and promoted independence skills which will enable the clients move on to more independent living situations wherever possible. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 13 The clients have meetings on a regular basis to discuss issues relating to the running of the Home, staffing and any individual issues that anyone might wish to raise. Clients are involved in the daily tasks within the Home such as cooking, cleaning, tidying their own bedrooms, washing up and looking after the various pets that live at the Home. Clients are also involved in the recruitment of the new members of staff if they wish to do so. One of the staff who spoke to the Inspector confirmed that this happened and on the day of the visit some prospective candidates for jobs were due to visit to meet the clients later in the evening as part of the recruitment process. The monthly quality reviews that the Proprietors undertake always involves the views of the clients and the Manager also provides a written response which includes the action taken following the responses to the quality review. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The clients are supported to take part in a range of leisure, work and educational activities. The clients and their relatives feel that they are supported to maintain contact in whatever way they prefer. Clients are involved in the whole process of meal choices, shopping and preparation. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 15 EVIDENCE: The clients gave lots of examples of the ways in which they spend their time. Some clients attend formal day services during the week whilst others attend a variety of day services on a part time basis, voluntary work, adults education classes and leisure activities. Clients also spend time at home learning new skills to assist them to live more independently and also looking after the pets that live at the Home. The main focus is for the clients to choose how they spend their time and for them to enjoy their days. Clients are very much part of the local community and use the local facilities such as social events, sports clubs, shops and pubs. Clients went to a table tennis club in the village on the day of the visit to the Home and one was getting ready to go to the local Speedway meeting. The clients are encouraged to make their own choices about how they wish to spend their time and are given support to do so. The Proprietors provide transport but clients also use the bus service to access the local towns. One of the clients told the Inspector about his recent holiday and how much he had enjoyed it. The care plans contain detailed information about the arrangements in place for each client to maintain contact with relatives and friends. Clients are supported to visit and stay at relatives homes if that is what they wish to do and relatives feel that they are made to feel welcome at the Home. The Proprietors and staff understand the importance of family relationships and the difficulties that these can sometimes cause for individuals. Support is provided to clients in these circumstances. The clients said that they are able to choose what they want to eat and one said that he can always have a snack, whenever he wants to which he said is particularly important when he returns from activities during the evening. Clients said that they make joint choices about menus but that if they then change their mind they are always able to have something else. Clients assisted with the meal preparation on the day of the visit and there was plenty of choices available. The clients who live in the annexe do their own cooking wherever possible or have minimal staff support to do so. They choose what time they have their meal and where they have it. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 16 Recently some of the clients were asked to prepare a buffet for the retirement party of one of the social workers and this was praised by people who attended. One of the recent quality reviews was with regard to meals and action was taken to address suggestions made by the clients. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of the clients are met to a high standard. Medication is well managed in a way which protects the safety of the clients EVIDENCE: The care plans contain detailed information about the personal and healthcare needs of the clients. Clients told the Inspector about regular appointments with dentist, optician, chiropody, psychiatrists etc. The AQAA includes details about the range of health/social care professionals who are involved in the clients lives. The Proprietors work hard to ensure that the health needs of the clients are met and that they have access to the full range of health care professionals, including paying for private appointments if this is in the clients best interest. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 18 Comment cards were received from health/social care professionals and these all contained positive comments. Some of the additional comments made within these are below: “they always go the extra mile” “they work in an open and transparent manner” “…really does try to respond to the needs of individual clients” “they are very co-operative and very helpful” “needs are met to an exceptionally high standard” Clients are able to have the choice about who assists them with personal care and the AQAA includes examples of how this takes place in practice. Clients told the Inspector that the staff are kind and that they are able to say who they would like to help them. Two of the clients are deaf and the staff team are currently learning British Sign Language. Three of the staff have undertaken more extensive training and so provide the majority of the support to the two clients. It is the Proprietors intention that all staff will undertake this training but at present the staff who have done it then pass on their skills to the other staff. The medication system was subject to a quality review recently and some improvements have been made as a result of this. A further improvement has been made since the last visit to the Home as, following a risk assessment, one of the clients has started to be more involved in looking after her own medication. All staff receive appropriate training with regard to the administration of medication. The medication system was not looked at during this visit but had been during the last visit to the Home. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The clients are confident that their views are listened to and are acted on. The clients are protected from abuse and neglect through rigorous training and monitoring of standards. EVIDENCE: The completed comment cards from the clients state that they feel safe at the Home and that they know who to speak to if they are unhappy about something. This was confirmed through discussions with clients during the visit. Clients are clear about who they would speak to and believe that action will be taken if they do raise any concerns. Clients said that the Proprietors speak to them “all the time” and that the staff “know me well”. They said that they can also bring up issues at the clients meetings or at their care plan reviews if they want to. The clients were seen to chat easily and in a relaxed manner with the Proprietors and staff during the visit. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 20 Additional comments made in the comment cards returned from relatives and health/social care professionals include the following: “… is run in an open and transparent manner” “(the proprietors) are willing to talk through problems” “there is an open door… no secrets…” “always willing to listen and to act if necessary” The Home have not received any complaints since the last Inspection and nor has CSCI. The Home has an effective complaints procedure which is available in alternative formats. Following a recent quality review a simple form, using simple language and pictures, is in each of the care plans and clients are able to fill this themselves or ask someone to help them to do so if they wish to. The AQAA identifies that further work will be taken to enable those clients with communication difficulties to raise concerns/make complaints. All staff receive training with regard to Safeguarding Adults and the staff who spoke to the Inspector have a good understanding of this issue and of the high standards that are expected of them by the Proprietors. The Proprietors have a good understanding of the procedure to be implemented in the event of an allegation being made and the procedure has been reviewed and updated since the last visit to the Home. The procedure is available in symbol format for the clients. The records relating to the clients financial affairs were not looked at during this visit to the Home. At the last visit records were seen for one of the clients and these were cross referenced with receipts and cash. These records are regularly checked by the Proprietors. The Proprietors would like all of the clients to have an advocate but this is not currently possible due to a lack of availability. The Proprietors encourage the clients to ask someone away from the Home to assist them with completing the comment cards so that they do not feel constrained in their answers. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The accommodation meets the needs of the clients. EVIDENCE: The house has been extended and provides semi-independent living for four ladies within an annexe attached to the main house as well as the accommodation in the main house. The accommodation in the annexe is of a very high standard as it has recently been redecorated and refurbished. All of the clients there have ensuite bedrooms and there is also a shared bathroom, lounge and kitchen/diner. The clients also have access to the communal areas in the rest of the Home. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 22 The accommodation in the main house is good but has not been as recently redecorated or refurbished. The Proprietors have an improvement plan in place for the rest of the building which is ongoing. Recently two of the bedrooms have had ensuite toilets and showers added to them which are a real benefit for those clients. The Proprietors intention is to provide ensuites to all of the bedrooms. The Home employs domestic staff and everywhere was clean on the day of the visit. The clients are encouraged to keep their own rooms clean and tidy. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 23 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 , 35 & 36 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The clients are involved in the recruitment process and the appropriate checks are carried out to provide protection to the clients. Staff receive good training and support to carry out their roles effectively. EVIDENCE: An effective recruitment process is followed which includes carrying out the necessary checks to provide protection to the clients. Staff are not able to start work at the Home until such checks have been completed. Clients are able to be part of the recruitment process if they wish to and receive support to do so. Staff who have recently been recruited confirmed that they were asked to complete the necessary checks and that the clients were involved in the recruitment process. On the evening of the visit some prospective candidates were due to visit to meet the clients as part of the recruitment process. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 24 Staff said that they had received, or are in the process of receiving, a very good induction period which included them shadowing more experienced staff and receiving a mix of formal and more informal training. The focus of the induction is for them to gain an understanding of the philosophy of the Home and to get to know the clients as well as to receive some of the mandatory training. The training records seen at the last visit show that more than the expected standard of 50 of staff have complete NVQ Level 2 and that others are undertaking Level 3 and other, more academic social care qualifications. Training is obtained through a variety of sources. Staff said that they receive good training which helps them to understand their role better and to provide better support and care to the clients. During both recent visits to the Home the clients spoke highly of the staff, saying that they are “lovely,” “very helpful”, and that they “really help me”. The staff who spoke to the Inspector were clear about their own role and how this fits in with the rest of the staff team. They were clear about the philosophy of the Home and were very enthusiastic about their work with the clients. Staff confirm that they receive formal supervision on a regular basis from the Proprietors and that regular team meetings take place. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 25 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The Home is run in the best interests of the clients with their views underpinning all developments. The health and safety of the clients and staff is taken seriously and action taken to address any issues of concern. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Proprietors jointly manage the Home. Barry Lord has completed the Registered Managers Award and Joyce Lord, as well as one of the senior care staff, are currently undertaking this award. The Proprietors have a clear vision for the Home which puts the needs of the clients first and understands the importance of assisting the clients to become more independent and supporting them to move to more independent living situations. The clients and staff spoke very highly of the Proprietors style of management which is clearly one which involves the clients and staff in any changes. Staff and clients feel that they are able to discuss any issues with the Proprietors and that they are always available for them to do this. The comment cards returned from relatives and professionals also confirm this view. The Home has a well developed quality assurance process which includes a variety of informal ways of obtaining the views of the clients, staff, relatives and professionals but also includes a more formal monthly quality review of a specific aspect of the service provided. Records are kept which show that action is taken to address any issues raised. The AQAA was completed to a very high standard and shows an objective review of the areas that the service does well as well as an identification of further improvements which could be made. One of the senior care staff is going to attend a training day about REACH standards which is a recognised quality assurance tool which the Proprietors may consider using. Regular health and safety monitoring is carried out throughout the year and action swiftly taken to address any issues highlighted during this process. Staff receive appropriate training and a sample of records seen at the last visit show that regular maintenance and servicing is carried out for equipment such as the fire safety equipment. One of the senior care staff was attending training provided by the Environmental Health officers at the time of the visit. The Proprietor said that the Fire Officer had recently visited and had been satisfied with the quality of the fire risk assessment. Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 27 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 Standard No Score 1 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 4 4 X X 3 X Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 28 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. 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 Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Coopers Mill Ltd DS0000070041.V350700.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!