Inspection on 12/02/07 for Copper Beech Services

This inspection was carried out on 12th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copper Beech Services 24/03/09

Copper Beech Services 24/01/06

Copper Beech Services 23/08/05

Copper Beech Services 10/02/05

Copper Beech Services 18/10/04

Copper Beech Services 22/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Copper Beech Services Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ Lead Inspector Stephen Webb Unannounced Inspection 12th February 2007 10:45 Copper Beech Services DS0000033966.V330586.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 Copper Beech Services DS0000033966.V330586.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. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Copper Beech Services Address Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 0208 954 4555 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) copperbeechannexe@norwood.org.uk bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood Mr Vernon Ambris Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Copper Beech Services is part of Ravenswood Village and is registered to provide support and care for sixteen adults with learning disabilities. The service is provided on two sites that were previously registered separately. The service has evolved and developed into a specialist residential resource for people with autistic tendencies, and there are plans to relocate the specialist service to new-build units in due course. Both current sites are purpose built single storey buildings. All of the service users are accommodated in single bedrooms. The home has equipment to assist the more dependent service users. Within the service three residents’ bedrooms are located in individual flats, to enable their more complex needs to be met through the provision of dedicated staffing and higher ratios, though they may also spend time with the group. The home manages a wide range of need, including challenging behaviour, epilepsy, and autism. The aims and objectives of the home are to provide a secure and comfortable home; encourage and support residents to make decisions and choices in their lives; support and assist service users to make and maintain satisfying relationships; assist service users to develop their skills; and enable service users to engage in valued day time occupation and use the community facilities. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.45am until 6.30pm on 12th of February 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. Additional information was also provided after the site visit. The report draws from conversation with the manager and brief conversation with staff members. Written feedback was obtained from the family of three of the residents and five healthcare professionals. None of the residents was able to communicate verbally with the inspector, so some time was spent observing the interactions between staff and residents. The inspector examined the communal areas of the premises and some of the bedrooms, and ate lunch with residents, as well as making informal observations of interactions between staff and residents at various points during the inspection. What the service does well: The needs of prospective residents are appropriately assessed and transitions are individually paced according to individual needs. Effective risk assessment systems are in place. An effective individualised daily record system is in use. The observed care of residents was good, with staff able to understand and interact with the residents. Residents were observed to make choices with support from the staff. Feedback from residents and healthcare professionals was also positive about the care provided. Residents are supported to use a range of communication methods by a speech and language therapist who also provides some input to staff to assist them in facilitating residents’ communication. Appropriate systems are in place to manage residents’ finances on their behalf. Residents can take part in a range of appropriate planned and impromptu activities both on and off-site, with support from staff, and have access to community events. Staff support residents’ links with family wherever possible, and alternative support is provided to those without ongoing family contact, via befriender/advocates. The spiritual needs of the residents, who are currently all of the Jewish faith, are well provided for within the village, which operates within a Jewish cultural framework. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 6 Residents are provided with a healthy diet, conforming to Kosher principles, and are consulted as far as possible when menus are planned. The healthcare needs of residents are met effectively. The home has an appropriate system to manage the residents’ medication on their behalf, and staff receive training in appropriate specialist areas. The service has an appropriate complaints procedure, though all of the current residents would be likely to need the support of an advocate to make a complaint. Relatives are satisfied that their views are listened to. Appropriate systems are in place to promote the protection of residents from abuse, and the residents are protected by sound staff recruitment and vetting practices operated by the provider. Residents are cared for within a physical environment that meets their needs satisfactorily. There are plans for a newly built unit to improve provision still further. It is understood that communal areas are due for redecoration after April 2007, which will further improve the environment. The health, safety and welfare of residents are generally promoted and protected. What has improved since the last inspection? What they could do better: There is a need to rationalise the care plan information which is currently spread across a number of formats, to ensure that the current information and goals are clearly evident. There is room for development of the level of resident involvement in day-today domestic tasks, and with regard to records of the individual preferences of residents, about how their care is provided. Some aspects of healthcarerelated recording should also be improved. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 7 There is a need to recruit to remaining vacant posts, to further reduce the level of agency staff usage, though some agency staff are working full-time, to maintain the consistency and continuity so important to the residents. There is a good core induction and training programme but the identified shortfalls in some areas, with regard to cyclical updates, need to be addressed. The recommended frequency of fire safety training to staff should be clarified with the fire authority and actioned. The manager should assess the need for individual fire evacuation plans for residents, and should obtain written confirmation that the issues raised within the fire authority deficiency notice have been addressed. The provider has yet to establish an appropriate quality assurance system though such a system is reported to be under development, and should be brought into use as a priority. 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. Copper Beech Services DS0000033966.V330586.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 Copper Beech Services DS0000033966.V330586.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 good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are appropriately assessed and transitions are individually paced according to individual needs. EVIDENCE: There had been no recent admissions to the unit, but the inspector discussed the provider’s procedure with the manager. Initial assessments of prospective new residents, are undertaken by the provider’s in house psychology department, along with the unit manager. If it appears that the person’s identified needs can be met, in the context of the needs of existing residents in the service, then initial visits are arranged, leading up to extended visits and overnight stays. An individualised transition plan is set up over the period that appears appropriate to the individual, though this remains flexible. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 10 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Though there remains a need for further development and improvement of the care plan formats, the observed and reported outcomes for residents were good, and the manager was in the process of reviewing the care planning system. Feedback from relatives and healthcare professionals was also positive about the home. It was possible to observe residents making and being offered choices in their daily life in the home, and some individual preferences were also recorded in their care records. Individual risk assessments were in place where necessary. EVIDENCE: The care records of two residents in each building were tracked as part of this inspection. Each resident has a day-to-day case file containing the information necessary for staff to meet their needs. This file includes an individual profile, a variety of care plan formats, separate formats describing routines at key Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 11 times of the day, a communication profile, activities plan, information and records regarding healthcare, a “My Health” booklet, and copies of behavioural guidelines and management plans where required. In addition there were copies of recent review reports and minutes, and monthly keyworker reports, which are used to summarise significant information and progress each month. The service is proposing to move towards a PCP care plan format and this will help to concentrate the relevant information, which is currently distributed across various formats, into one core document, which should optimise accessibility to staff. A lot of the information in the routines documents covering key parts of the day will transfer readily into the PCP format. The examined care plans contain details regarding individual’s skills, strengths and weaknesses and their history, but could be improved with more information on their likes, dislikes and individual preferences regarding their care and support. The Essential Lifestyle Plans on some files did contain some of this information, but these were not universally in use. Some of this information is available across the various formats, particularly within the records describing individual routines at key times of day, but it would be more readily accessed if held within a single format. These records also contain useful cross-referencing to other relevant documents, including risk assessments, which are held collectively elsewhere, for ease of access. However, the sections regarding “step-by-step guidance to complete tasks” tended towards being a list of issues and some information on preferences, rather than providing the detailed guidance implied by the heading, and this aspect of care planning and management requires further development. The manager understood the role of risk assessment and these documents were utilised to evidence individual staffing needs, and other additional support requirements. The care plan format, in one of the tracked files had not been fully completed, though relevant information was present in other formats. Since the identified format remains part of the current residents’ records, the manager should ensure that it is fully completed. Daily records are made within individually formatted bound logs, which enables specific targeting of the information required by the keyworker, in order to monitor progress on care plan goals, though the benefits of this opportunity are yet to be maximised, as the setting of detailed goals could also be expanded. These daily records also provide an ideal opportunity for recording the application and success of any planned behavioural interventions, to facilitate their monitoring. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 12 The files contained evidence of strategy meetings and other reviews of individual’s PIW behaviour management plans (Physical Intervention and Withdrawal), and also of planned and additional training provided to staff to support them in managing behavioural issues. Residents have little verbal communication though they are able to communicate their wishes via a range of alternative communication methods, including Makaton, Picture Exchange Communication System (PECS), pictures and symbols, Facilitated communication, TEACHH, objects of reference and yes/no cards. The home receives support and training on the application of the various communication methods from the in-house speech and language therapist. Observation of the interactions between staff and residents at various points during the inspection indicated that residents are able to communicate their wishes and preferences to staff that were familiar with their communication methods, and are enabled to make day-to-day choices in their lives. The preferences of residents are taken into account when planning holidays. None of the residents is able to manager their own monies and the service has an appropriate system to manage funds on their behalf, which includes ongoing in/out/balance records, with staff signatures, individual storage of funds and receipts for expenditure, and each resident has an individual building society account in their name. Residents’ financial balances and records are also regularly checked and subject to periodic external audit. Feedback from three GPs, two healthcare professionals and three relatives, via inspection comment cards was positive with regard to the care provided, with two of the relatives being particularly complimentary. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can take part in a range of appropriate planned and impromptu activities both on and off-site, with support from staff, and have access to community events. Links between residents and their families are maintained and supported where possible and alternative external support is provided to those without ongoing family contact, via befriender/advocates. Residents are supported to make day-to-day decisions in their lives by staff who are familiar with their individual communication methods, though there is room for further development of their direct involvement in daily tasks. Residents are provided with a healthy diet, which conforms to Kosher principles, and are consulted as far as possible when menus are planned. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 14 EVIDENCE: None of the current residents attend college placements, though two undertake supported paid work within the “village”. Each resident has an individual activity plan on file detailing regular scheduled activities, though additional impromptu activities also take place. Residents retain the option not to take part in activities and as already noted, the staff are familiar with individual’s means of communication to enable this. Residents have access to a range of activities, both on and off-site. Various sessional activities are provided by the in house day services and also via an external day service provider. Available sessions include music, sensory, arts and crafts, IT and communication. An external day service provider also provides on-site sessions to meet individual needs. Off site, residents go swimming, bowling shopping, and visit cafes, restaurants and pubs. All of the current residents are of the Jewish faith and their spiritual and cultural needs are met within the “village” via the celebration of festivals, the provision of a Kosher diet, attendance at the on-site Synagogue and through the support of the visiting Rabbi. The spiritual needs of those of other faiths would be met via visits to appropriate places of worship off-site. Holidays are planned according to the likes and dislikes of individuals. Where residents travel to a venue as a group, such as to Centre-parks in 2006, they often spend their time within small groups on various activities once on holiday. Small groups also go away together at times, and two residents travelled recently to the Isle of Wight. One resident is currently unable to cope with periods away from the home due to the resulting changes of routine, and tends to be provided with various day trips instead, though there are plans to try some short-stay breaks to see if these can be successful. Most of the residents have regular contact with family, via visits to the unit or to relatives, which are supported appropriately by the staff. Three residents have no ongoing family contact, but are supported by befriender/advocates instead, who take them out and attend reviews with them. Staff maintain appropriate contact with residents’ families, and this was confirmed by the three relatives who completed inspection comment cards. The manager acknowledged there was room for improvement in the level of residents’ involvement in day-to-day household tasks, and this was an area he had already identified for development. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 15 Pictorial menu boards are in use to support residents in making choices and photos of meals are used with residents when planning menus. All meals are now prepared within the unit using a high proportion of fresh ingredients. The meals are all provided within the constraints of the Kosher dietary requirements, to which all services in the village conform. In this unit the residents are involved as much as possible with shopping for food and go on shopping trips as part of independent living skills training, with staff support as defined by their risk assessment. Residents also accompany staff on periodic shopping trips to Golders Green to enjoy the wider aspects of Jewish culture, often including eating out in Kosher restaurants. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 16 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported effectively by the care staff in order to meet their needs, though there is room for improvement with regard to records of the individual preferences of residents, about how the care is provided. The healthcare needs of residents are met effectively, though healthcarerelated recording should be improved in some areas. The home has an appropriate system to manage the residents’ medication on their behalf, and staff receive training in appropriate areas. EVIDENCE: Residents’ case files included some details of how care is provided, within a variety of formats, as noted above, which would benefit from consolidation into a single consistent format. As already noted there was also a need for further development of these records in terms of greater detail on the preferences, likes, and dislikes of individuals with regard to how their care is provided. (Recommendation made under Standard 6). Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 17 Individual behaviour management plans were also in place where this had been found necessary, which identify how staff approach the management of specific behaviours, to maximise consistency of approach. Records of support from external professionals were also present including the in-house speech and language therapist. The Practice Coordinator on the staff team also has experience of some of the alternative communication techniques used, and provides additional input to staff. Each resident had individual healthcare appointment records maintained with a separate index sheet per healthcare profession, for ease of access for monitoring. Detailed individual records were also completed for each appointment, recording relevant information and outcomes, though some appointments did not appear to have been recorded and some forms were incorrectly filed. Keyworkers should be reminded of the importance of maintaining accurate and up-to-date records. At the point of inspection there was no available evidence that a previous inspection requirement to ensure regular eyesight testing for residents had been addressed, but the manager later confirmed that residents in one of the houses had received these checks in March/April 2006 and that appointments for two-yearly checkups were due for the residents in the other house this year. The records had been retained at the opticians, but the manager undertook to ensure that appropriate details were recorded within residents’ records as well. Other healthcare records included a weight-monitoring chart, though in one case the last entry was dated 9/06, which is unsatisfactory. Copies of the “My health” booklet were also found on some files. None of the residents is able to manage their own medication, but the home has an appropriate system to manage this on their behalf. The system includes records of the quantities of medication received by the home and a returns log. A double signatory system for recording medication administration was in use in one house and was due for introduction in the other house, in the near future. Medication records also included individual medication profiles updated in January 2007, and residents’ photographs, as well as guidance on any specific administration methods for individuals. The use of specific homely remedies had also been approved in writing by the GP, which is good practice. Staff training records indicated that care staff receive training on medication administration, first aid and epilepsy awareness on a rolling programme. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 18 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has an appropriate complaints procedure, though all of the current residents would be likely to need the support of an advocate to make a complaint. Relatives are satisfied that their views are listened to. Systems are in place to promote the protection of residents from abuse. EVIDENCE: The service has a written complaints procedure, and there is also a separate leaflet for relatives, and a version in symbol format which is gone through with the residents. The manager was hoping to develop a simpler residents’ version based on faces and a yes/no format, as he felt this would be more readily accessible to residents. The three relatives who completed inspection comment cards confirmed they were aware of the complaints procedure, and one noted that a complaint they had made previously had been dealt with. The complaints log had no entries in the past year. The manager explained that any comments made are acted upon immediately and have therefore not necessarily been logged as complaints. It is suggested that wherever negative feedback or comments are received, they are logged as informal complaints, where appropriate, in order to Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 19 demonstrate that the process undertaken to address them, conforms to the complaints procedure. No Protection of Vulnerable Adults, (POVA) related issues have arisen in the unit since the last inspection. The service has an appropriate procedure for protecting residents, including for the protection of residents’ finances, and links in with the local multi-agency protection procedure as appropriate. The manager is appointee for all of the residents’ funds as none are able to manage their own money. The staff receive POVA training as part of induction, from an in-house accredited trainer and refresher training is provided on a rolling programme. (See Staffing section for further discussion re POVA training). Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with an environment that is homely and comfortable and meets their needs. Separate individual accommodation is provided for some residents to enable appropriate support to be provided. The home was found to be clean and hygienic. EVIDENCE: The current service is provided within two separate buildings, which provide single bedrooms for each resident, some of which are within individual flats, to enable effective behaviour management and additional focused staff support. There are no special requirements for additional aids and equipment to meet the current needs of residents. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 21 The décor and furnishings within the two buildings were satisfactory, though some of the communal areas would benefit from a coat of paint. It is understood from the manager, that the unit is scheduled for redecoration of the communal areas in the period after April 2007. The manager indicated that the residents will be consulted about the new colour scheme. The residents’ bedrooms inspected, were individualised to reflect the interests and personality of their occupant, and pleasantly decorated. The bedrooms in Copper Beech were smaller in general than those within the annexe. Laundry facilities meet the needs of the service and standards of hygiene in the home were good. There are plans for the building of a new specialist Autism unit within the village, currently projected to be available during the spring or summer of 2008, which will provide smaller living groups for some of the residents. The manager undertook to keep CSCI informed of progress. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 22 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent permanent staff team, of whom a high proportion, have attained at least NVQ level 2 or equivalent. Although the level of agency staff usage in the unit remains high, the effects of this are minimised by using some agency staff to cover vacancies full time, to maximise the continuity of care to residents. The residents are protected by sound staff recruitment and vetting practices operated by the provider. The core induction and training programme provided to staff, enables them to meet residents’ needs, but the identified shortfalls in some areas, with regard to cyclical updates, need to be addressed. The recommended frequency of fire safety training to staff should be clarified with the fire authority and actioned. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 23 EVIDENCE: The staff team has a stable core of established staff though significant levels of agency staff are still utilised. The manager is seeking to continue to broaden the level of skills in the team to enable them to further support the development of residents’ skills and abilities. To date the care staff have had little involvement in developing practice and care planning etc. and there are plans to provide support and training to enable increased involvement at this level. Observations of staff interactions with residents were positive and the staff demonstrated a good understanding of individual’s communication. Feedback from relatives was positive about the care provided by the staff. The staff spoken with, were aware of their role and of the need for recordkeeping and care plans. At the time of inspection 85 of staff had attained at least NVQ level 2 or equivalent, though this does not include the agency staff used. The manager indicated that there were 2.5 full-time equivalent care staff posts at the time of inspection, and this, together with relatively high levels of sickness was the reason for the high agency usage. The manager tries to use agency staff who are familiar with the unit and its residents, in order to maximise the consistency and continuity of care provided, and given the additional needs of those residents who live in the individual flats, agency staff working with these residents tend to work fulltime, rather than working casual shifts. This is appropriate as it is the preferred option to maximise the quality of care provided in terms of consistency of approach, and residents’ familiarity with those providing their care. The recruitment and vetting records for three recent recruits were inspected and indicated a thorough recruitment and vetting procedure, and the staff records were indexed and maintained to a clear and consistent system. The provider has a cyclical programme of induction and foundation training on a rolling programme. The reported frequency for refresher training on the protection of vulnerable adults is three yearly, which is considered an extended period between episodes of this training, though the training is provided by an in-house accredited trainer. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 24 However, examination of the training records provided, indicated five staff who were not recorded as having received POVA training within the past three years. Any staff who have not received POVA training according to the provider’s own cycle should be provided with this as a priority. Consideration should be given to whether interim in-house POVA updates, led by the manager perhaps as part of a team meeting, would be beneficial on an annual basis in addition to the cyclical provider training, in order to maintain an ongoing awareness of POVA issues. Details of training content and attendees should be recorded for any such training updates. Similarly, the provider’s reported cycle of refresher training for fire safety training is also three yearly, though examination of the training records provided, again indicated six staff who do not appear to have received this training within the given period. This must be addressed as a priority. This is an extended period between refresher training, in such an area as fire safety training, which might be better provided annually. The appropriate frequency for fire safety training updates should be clarified in writing with the fire authority and actioned. Copper Beech Services DS0000033966.V330586.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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a well run home. The manager has identified areas for improvement, and though some shortfalls have been identified, they have not been shown to impact negatively on residents. The feedback from relatives and external professionals, via comment cards was positive. The provider has yet to establish an appropriate quality assurance system to obtain the views of residents and others about the service provided, though such a system is reported to be under development. Residents do have access to other opportunities to raise any concerns, though, given their particular needs, they would need to be supported by someone familiar to them, in order to express their views. The health, safety and welfare of residents are promoted and protected, for the most part, though the manager should assess whether individual day/night fire Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 26 evacuation plans need to be devised for any of the residents, and written confirmation should be obtained that the issues raised within the fire authority deficiency notice have been addressed. EVIDENCE: The manager is appropriately qualified and experienced to run the unit. He has NVQ level 4 and the Registered Manager’s Award and is an internal assessor. He also has a City and Guilds certificate in Management in Care and a counselling qualification. The manager attends ongoing training to maintain an up-to-date knowledge of practice. In conversation the manager expressed the strengths of the unit clearly and also highlighted areas where further development was required. He had begun to address a number of issues. As yet, no quality assurance survey has been undertaken by the provider. The required quality assurance system is reported to be under development. A senior management team is reported to be currently working on developing this system, which must be put into operation as soon as possible. The views of residents, relatives and other interested parties, such as care managers and healthcare professionals, should be sought as part of this process, and this is usually achieved via targeted questionnaires. Provision will need to be made for residents to be supported to complete their questionnaires. It is acknowledged that support provided by an external advocate or other person from outside of the unit, may not be successful, (due to the specific needs of residents), so it may be necessary for keyworkers to undertake this task in this unit. A summary report should be produced of the findings of the quality assurance survey, which should indicate the proposed actions in response to any issues raised. The report should be made available to participants and other interested parties. The provider does have a system of Lay Monitor visits, usually parents of service users, who undertake periodic visits during which they spend time with residents and staff, and produce a report of their findings, though these reports are not made public. The provider also undertakes regular Regulation 26 monitoring visits and reports are copied to the unit. The manager had carried out his own survey of some of the residents just prior to the inspection, with keyworkers supporting the residents. Three residents took part and two others declined. Examination of a sample of health and safety-related service certification indicated these to be up-to-date with the exception of the five yearly electrical Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 27 installation certificate, which was overdue but pending as the contractor was working round the various units in the village. In future servicing should be arranged within the required periods, The home has an appropriate set of individual risk assessments which are held collectively for ease of access and available to staff. The unit has a fire risk assessment in place, last reviewed in December 2006, though at present there are no individual fire evacuation plans. One resident had remained in their flat during the latest drill/evacuation in December 2006, though no such issues were noted at the three previous evacuations. It is recommended that the manager review the drill/evacuation records over the next few drills to ensure that the behaviour of any resident on hearing the fire alarm, does not indicate the need to prepare an individual day/night fire evacuation plan. From the records available at the time of inspection it was unclear whether cold smoke seals and intumescent strips had been fitted to the remaining fire doors, following the deficiency notice from the fire authority dated 14/6/06. The manager subsequently reported that from his visual check they appeared to be in place, and written confirmation was being sought. Examination of the accident recording system indicated that this unit has both the required individual accident records (within residents’ files), and a collective record, available for monitoring. However the new accident recording procedure remains unclear about the eventual destination of copies of accident forms, which should be as above. The new accident recording procedure dated 15/1/07, requires that staff include their own home address on accident forms, rather than “care of” the home address. It is suggested that the necessity for this should be checked with HSE as it could compromise staff confidentiality if a relative requests sight of the form, as is their right. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 28 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 3 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 3 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 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 2 X X 2 X Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 29 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 YA6 Regulation 15(1) Requirement Timescale for action 12/04/07 2. YA18 13(1) & 17(1)(a) 23(4)(d) & 13(6) 3. YA35 4. YA39 24 The manager must ensure that the care plan documents on residents’ files are fully completed in all cases. The manager must remind staff 12/03/07 to ensure that healthcare records are complete and up-to-date at all times. The manager must ensure that 12/04/07 all staff receive fire safety and POVA training updates to at least the provider’s own stated frequency. The provider must establish an 12/04/07 appropriate quality assurance system to seek the views of relevant parties about the operation of the home, in a systematic way. A summary report of the findings of the survey, should be made available to participants. Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that the information from the various formats within case records is consolidated within a single current document, in preparation for the move to the PCP system, and that the previous formats are then archived, to increase the ready accessibility and focus on the current issues and needs. It is suggested that the valuable information on residents’ preferences, likes and dislikes around their care, which appears within the individual profiles, is also included within the consolidated new care plan format. Written confirmation should be sought from the fire authority regarding the appropriate frequency for staff fire safety training updates, and this should be actioned. Consideration should be given to the benefits of providing POVA updates to staff with greater frequency than this is currently provided. The manager should review the need for any individual day/night fire evacuation plans for any residents, and devise these where there is a demonstrated need. Written confirmation should be obtained from the provider, that the requirements of the fire authority deficiency notice have been addressed. 2. YA6 3. 4. 5. 6. YA35 YA35 YA42 YA42 Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Copper Beech Services DS0000033966.V330586.R01.S.doc Version 5.2 Page 32 - 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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