Inspection on 13/02/07 for Copperbeech Care Home

This inspection was carried out on 13th February 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

Copperbeech Care Home 03/12/08

Copperbeech Care Home 01/08/08

Copperbeech Care Home 13/03/08

Copperbeech Care Home 11/05/07

Similar services:

Deepdene Care Centre

Ferndale Residential Care Home

David Gresham House

Elizabeth House

Elvy Court Nursing Home

Fontenay Nursing Home

Clairmont Residential Home

Cornford House

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

CARE HOMES FOR OLDER PEOPLE Copperbeech 154 Barnhorn Road Little Common Bexhill-on-Sea East Sussex TN39 4QL Lead Inspector June Davies Unannounced Inspection 13th February 2007 10:00 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 Copperbeech DS0000067146.V325785.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. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Copperbeech Address 154 Barnhorn Road Little Common Bexhill-on-Sea East Sussex TN39 4QL 01424 842770 01242 842770 copperbeachemi@btconnect.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) Meeraraj Limited Ms Clare Vilma Sobhanieh Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users should be aged sixty-five (65) years or over on admission. The maximum number of service users to be accommodated is twenty (20). Only service users with a dementia type illness to be accommodated. Date of last inspection New registration. Brief Description of the Service: Copperfield Care Home for older people with dementia is situated on the main road just outside the village of Little Common, Bexhill on Sea. The home is a detached house in keeping with all other residential property in the area. The home is registered to provide care for 20 residents, at the time of the inspection all rooms with the exception of one are single. The bedrooms are situated on the ground and first floor. The residents have a choice of well furnished communal lounge areas in which to sit. Mealtimes are flexible within reason, and food is of a good quality. The first floor is accessible via a shaft lift. The home does have hoisting equipment to ensure that residents can be moved and bathed safely. All bedrooms are well decorated and have domestic style furniture, but residents are encouraged to bring their own personal items into the home with them. There is a secure garden area sited at the front of the property to which residents may have access at any time. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, taking place over a period of seven hours. During the inspection the inspector talked to the registered manager, some of the residents and staff, and viewed all documentation relevant to the standards inspected. Those residents who were able said that they like living in the home, the staff were kind and considerate and that the quality of the food was good. Staff said that the new registered provider had made a lot of improvements to the home, and that it was a much nicer place to work in, all spoke highly of the registered manager. What the service does well: What has improved since the last inspection? What they could do better: Residents’ daily records should not be kept collectively, and further work needs to done to ensure that the activities programme meets the needs for dementia care. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 6 The complaints policy and procedure needs to be displayed in the home to ensure that all residents and visitors have sufficient information should they need to make a complaint. Work still needs to done to ensure that medication is recorded when it is received into the home mid-month. Staff must ensure that controlled drugs are recorded appropriately and any errors are reported directly to the registered manager. Further refurbishment and renewal and maintenance needs to take place especially with kitchen flooring and the delivery of hot water in the home. One bedroom has an offensive odour that must be overcome. Two references must be sought for all new staff. Staff mandatory training must be kept up to date, and all staff need to undertake appropriate dementia care training to ensure that they have good understanding of residents assessed needs. All new staff must undertake Skills for Care induction. The registered provider must ensure that at least 50 of staff in the home have achieved NVQ level 2. Quality assurance needs to be developed further to ensure that all systems used in the home are monitored on a regular basis, to ensure that the standard of care and well-being is of a good quality. 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. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. Residents know that their personal needs will be reflected in their individual care plans and that potential risks are managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager always carries out a pre-admission assessment of prospective new residents into the home. Care manager pre-admissions are not always forthcoming. Evidence was available on pre-admission assessments that where the registered manager cannot obtain sufficient information at the pre-admission assessment she will also contact the prospective resident’s G.P., District Nurse etc to gather further information. . Under each heading assessment there was detailed hand written evidence gathered at the pre-admission visit. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 9 The home does not offer intermediate care. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8, 9 and 10 Quality in this outcome area is adequate. Residents know that their personal needs are reflected in their individual plans and that potential risks are managed. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The system for administration of medication needs to be improved upon so as not to place residents at risk. Personal care is offered in a way to protect resident’s privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the present time the home has 15 residents one is in hospital. The inspector viewed four care plans each care plan was comprehensively written to individual assessed needs. All care plans contained the preadmission assessment carried out by the registered manager, a needs led care plan, weight chart, medication, past medical history, recent medical Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 11 investigations, current medication, recent history, social history, risk assessments. Each care plan contained evidence of monthly reviews by the key workers and registered manager and six monthly reviews, which in some instances involve relatives and multi disciplinary workers. The daily report at the present time is kept collectively in one book, and the inspector is making a recommendation that each care plan contains a daily report sheet. Care plans state what assistance is required with personal hygiene, and according to assessed needs this varies between each care plan. Care staff report in daily report where personal care is being given, and at the present time the registered manager is considering a personal hygiene matrix to be included in the plan, to ensure that staff have carried out important checks while assisting residents with personal care. Any concerns regarding tissue viability are reported immediately to the district nurse. The inspector observed that residents who are at risk of pressure areas are supplied with pressure relieving equipment. The continence nurse visits the home every six months to assess those residents supplied with continence aids, should the home have a new resident admitted who requires some assistance with continence, the registered manager will telephone the continence nurse to visit the home, to enable an individual assessment to be carried out. The community psychiatric nurse visits certain residents in the home, and four residents have regular appointments with the psychiatrist. A music therapist visits the home monthly. The registered manager recognises that more needs to be done to provide exercise for the residents in the home. All care plans viewed by the inspector showed a weight chart and that residents are weighed every month. Residents are able to choose a G.P. of their choice if they come into the home from the locality, those residents moving into the home from outside the area, are signed on with a G.P. who has vacancies on this books. Residents see a visiting chiropodist every eight weeks, an optician visits the home annually, and a visiting dentist carries out annual dental checks. Those residents who wear a hearing aid attend the local hospital audiology department as and when required. A physiotherapist will visit the home on referral from G.P.’s. The home has a recently reviewed medication policy and procedure, and there is a list of staff that are trained to administer medication together with signatures and initials. The home uses Boots the Chemist monthly monitored dosage system. The inspector viewed the MAR charts and found them to be correctly signed on administration of medication, the inspector did note that medication brought into the home mid month is not always properly recorded onto the MAR sheet with date of receipt, quantity of medication and initials of the person checking the medication in. The returned medication book showed that medication is returned to the pharmacy on a monthly basis. The home uses a drugs trolley and this was clean and tidy on the day of the inspection and was safely bolted to the wall. On inspecting the controlled drugs kept in the home, the inspector noted an error between the controlled drugs register and the amount of controlled drugs tablets for one resident. The medical Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 12 refrigerator was in a clean and tidy condition, and regular daily temperature checks are carried out and recorded. Personal care is carried out in the residents’ bedrooms or in one of the communal toilets or bathrooms. Staff always make sure that doors are shut and the residents dignity and privacy are maintained. None of the residents have their own personal telephone in their bedrooms, but they are able to use the office telephone in private if they wish, and will be given assistance to dial the number. Due to the level of dementia in the home, many of the residents would be unable to see a G.P. alone; usually a member of staff is available to ensure that the resident has their condition explained to them. The inspector noted during the inspection that staff address the residents by their preferred name as recorded in their care plans. At the present time there is only one double room in the home, and privacy screens are available for when personal care is being carried out. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. A range of activities are provided for the residents, but more innovative work needs to be done, to provide activities that residents can enjoy. Visitors are welcomed into the home at any time. Their families or legal advisers manage residents’ financial affairs. The meals in the home are good offering both choice and variety and catering for special diets. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The activities rota is placed in the main hallway of the home. The registered manager stated that it is difficult to involve residents in group activities, and staff find themselves providing activities on a one to one basis with a resident. Discussions took place regarding the need to be more innovative with activities and considering more tactile activities for the residents in the home. The inspector noted that past interests and activities were recorded in each resident’s care plan. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 14 The registered manager is in the process of introducing person centred planning, and key workers are about to work in groups with residents on these. Residents are able to choose when to get up in the morning and go to bed at night. Both the registered manager and staff said how much the residents enjoyed musical entertainment, and especially when the musical therapist comes into the home. She brings in a variety of musical instruments, which the residents can play if they wish to. At the present time the home has no practising Catholics, but arrangements can be made for a priest to visit should the need occur. Other residents who are Church of England are able to have communion on a regular basis if they wish to do so. The home has a visiting policy that has recently been reviewed and information regarding visiting is also available in the homes service user guide and statement of purpose. Visitors are welcome into the home at any time and are free to take their resident out if they wish to. As stated previously in the report two ladies come into the home on a monthly basis to provide musical entertainment and therapy of the residents. Due to the dementia levels of the residents none are able to look after their own financial affairs, and relatives and solicitors provide assistance for this. The registered manager is in the process of obtaining information regarding advocacy from ‘Help the Aged,’ for those relatives who might be interested, and for one resident who has no living relatives. Should a resident request to look at their care plan access to the individual plan would be made available. Three residents’ stated that the food in the home was very good, and positive feedback was also received via the service users surveys (mostly completed by relatives). The home caters for those residents who have liquidised food and each item of food is liquidised separately. The only specialised diet is for diabetic, but should the need arise other diets can also be catered for. On the day of the inspection residents lunchtime meal was roast lamb, roast potatoes and vegetables, with a choice for those residents who did not want the main menu, there was also a choice of sweet. The home has two separate dining areas; one dining room is used for those residents who need assistance with eating or prompting. Mealtimes are unhurried and in pleasant surroundings. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 Quality in this outcome area is good. The home has a satisfactory complaints system, but this need to be displayed to ensure that residents and their visitors are aware of the procedures for making a complaint. The arrangements for protecting residents’ are satisfactory to ensure they are not at risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure was reviewed six months ago, and stipulates that time that complaints will be responded to. The inspector noted that this policy and procedure was not displayed in the home. The home has complaints sheets, where any complaints will be noted, together with space for how the complaint was investigated, and when the reply was made to the complainant. The home has not received any complaints since the new registered provider took over the home. The home has policies and procedures in place relating to abuse and whistle blowing. The registered manager told the inspector that the home also uses East Sussex County Council’s protocols for the protections of vulnerable adults, and was able to produce a copy of this document during the inspection. The policy and procedure for staff dealing with aggression from residents needs to Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 16 be reviewed to ensure it contains sufficient guidance for staff. There are no outstanding adult protection issues in the home. Staff are informed within the staff handbook, through induction and NVQ training about the protection of vulnerable adults. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 17 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): Standards 19 and 26 Quality in this outcome area is good. Recent investment has significantly improved the appearance of this home creating a comfortable and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector carried out a tour of the home during this key inspection. During discussion with staff members on duty the inspector was told that the new registered provider has improved the aesthetic appearance of the home since he took over six months ago. The communal rooms were light and airy, decorations and furniture are homely and domestic in style. Many carpets have been replaced. There is an ongoing programme of refurbishment, replacement and decoration. The inspector did note that flooring just inside Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 18 the kitchen door was worn and had been patched but this has now deteriorated and is in a dangerous state. The residents have access to a secure garden via the patio doors in the communal lounge, the garden does at the present time need attention, but due to the weather this has not been possible, and the residents do not use the garden during the winter months. The laundry room is sited away from the kitchen area. The laundry has an industrial washing machine with sluicing and disinfecting programmes, a domestic washing machine used for delicate clothing and tea towels and an industrial tumble drier. The inspector noted that hand washing facilities with liquid soap and paper hand towels are provided in the laundry room and in communal toilets and bathrooms throughout the building. All clinical waste is managed appropriately and put into a clinical waste bin sited in the sluice room, and then removed to a clinical waste bins outside the building for collection. Staff are provided with disposable gloves and plastic aprons for clearing up spillages and bodily waste. Blue disposable gloves are used in the kitchen and for dealing with food. During the tour of the building the inspector did note that one bedroom had an offensive odour. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. Staff training needs to improve to ensure that assessed care needs of residents are appropriately met. Recruitment policies need to be consistently followed to ensure that residents receive care from appropriately vetted staff. The arrangements for staff induction need to be improved upon to ensure that staff can demonstrate a clear understanding of their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the present time the home uses 420 Care hours per week, some staff said that they do find themselves rushed at busy periods during the day. The duty rota showed that three staff are on duty during the morning, three staff on duty afternoon and evening and two waking night staff on duty with a senior member of staff on call. At the present time only two out of the twelve care staff have a NVQ level 2 or above, therefore only 16.2 of staff have a qualification. The registered manager confirmed that a further seven staff are in the process of completing of their NVQ which will then give 75 of care staff with NVQ qualification. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 20 The inspector viewed four staff personnel files, all files contained application forms, CRB checks and POVA first checks, two files had two references and two files only had one reference, each employee had a statement of terms and conditions. All new employees are given the GSCC code of conduct. While some staff have received some mandatory training, the inspector found that there were still gaps in mandatory training, all but one member of staff had moving and handling training, not all staff had first aid training, only nine staff had fire safety training, three staff had health and safety training, very few staff had infection control training and six staff had food hygiene training and only two staff had POVA training. Further mandatory training is booked in March 2007. The inspector also found that none of the staff had received appropriate dementia care training. While staff have received health and safety induction training, none of the newer staff had skills for care induction. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35 and 38 Quality in this outcome area is good. The manager has a good understanding of what needs to improve in the home. Planning is in place and sets out how this improvement will be resourced and managed. Further work still needs to be carried out on the quality assurance system to ensure that residents receive a high standard of care. Generally health and safety in the home is good but further work needs to be done to ensure that residents are safe at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 22 The registered manager has a NVQ levels 1 and 2 in business administration, a D32 and D33 assessors award, has completed a POVA trainers course and at the present time she is in the process of studying for RMA, which should be completed in June 2007. She has seven years experience at management level. Staff spoken to during the inspection said that they found the manager to be open in the running of the home and that she provides clear leadership throughout the home. The registered manager is in the process of further developing the quality assurance system within the home. At the present time questionnaires have been compiles for relatives and staff, but there is not a questionnaire for stakeholders in the community. The inspector saw evidence of an annual development plan for refurbishment, renewal and redecoration. The registered provider carries out monthly regulation 26 visits; these are recorded and kept in the home. The last staff meeting was held in November of last year. A health and safety audit has been carried out for the home, and this takes place six monthly together with a daily audit carried out by staff. Fire systems within the home are tested weekly, and there has been a fire risk assessment carried out in the last six months. The registered manager still has to develop a monitoring of systems in the home, to include medication, care plans, daily reports, reviews, food, staff files, laundry, and cleaning standards. Policies and procedures relating to the running of the home, and for the residents safety are still being reviewed and updated. The home does not hold any personal monies on behalf of the residents in the home. Families of residents deal with all personal monies; any expenditure made on the resident’s behalf is billed directly to the relatives of that resident. Relatives are requested to take valuables belonging to the resident’s rather than being kept for safe keeping within the home. The policies and procedures relating to health and safety are in the process of being reviewed and updated as required. As reported under standard 30 staff training in relation to safe working practices needs to be kept up to date. The inspector viewed up to date certificates for all equipment used in the home. The inspector did note that hot water delivery varies around the home from 30ºC to 39ºC with one hot water delivery at 47ºC. Discussion took place with the registered manager regarding having the hot water regulation valves adjusted on each hot water tap. Windows throughout the home are fitted with window restrictors. The inspector viewed building health and safety risk assessments and building fire risk assessments. All resident/staff accidents are recorded appropriately, and a file is kept with all completed accident forms. All new staff do receive health and safety induction training, but not to Skills for Care standards. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 17 (1)(a) Sched. 3 (3)(i) Requirement All medication brought into the home must be recorded onto the MAR sheet with the date of receipt, quantity of medication prescribed and initials of person receiving the medication. Controlled drugs must be closely monitored and only signed off by two members of staff who have accredited training; any errors must be reported promptly to the registered manager. Kitchen floor must be replaced to ensure safety for staff using this area. The offensive odour in one bedroom must be addressed. Two written references must always be obtained prior to staff being employed in the home. All staff must have up to date mandatory training and appropriate dementia care training. New staff must undergo Skill for Care induction training. DS0000067146.V325785.R01.S.doc Timescale for action 26/03/07 2. OP9 13(2) 26/03/07 3. 4. 5. 6. OP19 OP26 OP29 OP30 23(2)(b) 16(2)(k) 9 (4)(c) Sched. 2(5) 12(1)(a) 18(1)(a) (c) 28/04/07 26/03/07 26/03/07 28/04/07 Copperbeech Version 5.2 Page 25 7. OP38 13(4)(c) All valves on hot water taps to be tested to ensure that hot water is delivered at 43ºC 26/03/07 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. 2. 3. 4. 5. 6. Refer to Standard OP7 OP12 OP16 OP18 OP33 OP28 Good Practice Recommendations Daily reports should be kept in individual care plans and not collectively. Further work needs to done to provide appropriate activities for the residents in the home. The complaints procedure must be displayed in the home. The aggression to staff policy and procedure must be reviewed. Quality assurance to be further developed to ensure all systems used in the home are monitored. NVQ level 2 training to continue to ensure that at least 50 of care staff have this qualification. Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Copperbeech DS0000067146.V325785.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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