Inspection on 23/08/05 for Copper Beech Services

This inspection was carried out on 23rd August 2005.

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 found no outstanding requirements from the previous inspection report, but made 2 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 12/02/07

Copper Beech Services 24/01/06

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 RG45 6BD Lead Inspector Stewart Mynott 23 rd Unannounced August 2005 9.45am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Copper Beech Services Address Ravenswood Village Nine Mile Ride RG45 6BD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01344 755527 Norwood Ravenswood t/a Norwood Mrs Susan Walker Care Home 16 Category(ies) of Learning Disability (LD) registration, with number 16 both of places COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10 February 2005 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 previosly registered separately. The service has evolved and developed into a specialist residential resource for people with autistic tendencies. Both sites are purpose built single storey buildings. All service users are accommodated in single bedrooms. The home has equipment to assist the more dependent service users. The home manages a wide range of need, including challenging behaviour, epilepsy, autism . The aims and objectives of the home is 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 H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place during the day and lasted for 6 ½ hours. The manager gave a tour of both sites during which most staff and service users were met. Time was spent equally in both sites. In the annex time was spent observing daily life with service users and four staff were spoken to. Service user records were also examined. In copper beech time was spent with the registered manager, which included discussion about the ethos of the services provided. More of the homes records were examined in Copper beech. What the service does well: What has improved since the last inspection? What they could do better: This was a positive inspection with most standards being met or exceeded. However some work is required to ensure risk assessments for safe working practises are regularly reviewed and temperatures are recorded when serving hot foods in line with good practise. A recommendation was made to re-introduce the internal procedure for monitoring quality of procedures and records. Copper beech décor is dated and some improvements should be considered to provide a more homely environment for service users. A minor issue with recording of complaint outcomes in line with the Provider’s policy was also noted. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 6 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. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 4 Service users benefit from an excellent approach of planning and assessment that tailors a service to meet their individual needs. EVIDENCE: One recent admission to the home for a service user requiring a bespoke service was tracked. The service user benefited from a highly planned, detailed and thorough assessment and transition plan. This included planning meetings, visits and preparation including the use of “social stories”. An excellent utilization of staff to assist during the settling in period was also observed. Discussion with staff and observation demonstrated a commitment to provide an individual service, which supports new service users. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 Service users needs and goals are recorded in individual plans that are regularly reviewed. Service users are supported in all aspects of daily life within a good risk assessment framework. EVIDENCE: Each service users has a “key file” which contains information including an individual plan. In Copper Beech three service users plans were examined. Each followed an essential lifestyle plan format that clearly states the support needed from staff to assist in meeting assessed needs. The plans also recorded goals for the coming year, which were judged as achievable and realistic. Service users were observed to use specialist programs to assist communication that includes the use of TEACHH principles. This information was detailed in individual plans examined. Three service users plans were examined in the annex and were not completed to such a detailed level with some information incomplete. In all cases annual reviews had occurred and this was evidenced in key files. Service users daily life and choices are also supported by comprehensive risk assessments. These were supportive to ensure all daily activities remained safe. These are kept in a separate file for staff access and evidence was recorded that staff had read and signed as understanding these assessments. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 11 to 17 were not assessed during this inspection. EVIDENCE: COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 18 to 21 were not assessed during this inspection. EVIDENCE: COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Concerns and complaints are acted upon and investigated although some of the homes records were not completed. Service users are protected from harm through robust procedures and appropriately trained and knowledgeable staff. EVIDENCE: There is a comprehensive complaints and concerns policy within the home and a pictorial policy within the service user guide. There is complaints record in both sites and these were examined. There was one recorded complaint since the last inspection however the outcomes were not recorded as detailed in the homes complaint policy. A complaints officer in the village further reviews all complaints and again this process was not evidenced. Staffs were spoken to in regards to the understanding of the complaints policy, referred to this recorded complaint. Staff described how the complainant was supported and described a team response to resolve all issues. Staff further demonstrated a clear understanding of how to deal with complaints. A recommendation that the homes policy is followed to document outcomes has been made. The manager identified that many service users would need assistance to access the complaints procedure and staff spoken to and confirmed that they would access the procedure should the need arise. The home also has a comprehensive abuse policy, which serves to protect service users. Staff training records demonstrated that staff had received protection of vulnerable adults training. Some service users have very complex needs and can display behaviour that challenges the service. Staff discussion and care records revealed a good understanding and intervention procedures were appropriate to protect service users from self-harm. A sample of staff training records for staff supporting service users in two self contained flats revealed training for dealing with challenging behaviour had been undertaken. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 13 A recent case of an unexplained minor injury noticed by a support worker was thoroughly investigated and appropriate agencies notified as a possible POVA incident by the registered manager. The manager had clearly followed all guidelines and her investigation revealed that this incident was not a protection issue. However the senior staff member this was initially reported to had failed to follow internal procedures leading to a delay in initiating an investigation. The registered manager has already taken appropriate steps to prevent this situation reoccurring and therefore no requirement by the inspector was made. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27 and 30 Both sites provide a clean, comfortable and hygienic environment. Copper Beech’s internal décor was noted to have a dated appearance. EVIDENCE: Copper beech services now encompass two sites. Both of these were toured with the assistance of the home manager. Copper Beech annex provides modern, purpose built accommodation including two separate flats each accommodating one service user. The interior is well maintained and decorated and provides a homely and comfortable feeling for service users. Service users were enjoying the communal area and the dining room was calm and arranged appropriately for people with autistic tendencies. The standard of cleanliness was excellent. Copper Beech is also a purpose built accommodation with an internal conversion for a flat supporting one service user. The home is maintained and well decorated however the overall décor and finish gave a dated appearance. The suspended panelled ceilings particularly added to this dated appearance. The current provision of fluorescent lighting noted in the corridors also detracts COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 15 from a homely feeling. All bathrooms seen contained fittings and fixtures with flooring that is worn and stained in most cases. Service users bedrooms in both sites were clean and comfortable and personalised to individual’s tastes. The laundry in both sites are organised and clean and appropriate cross infection prevention procedures are in place. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 31 to 36 were not assessed during this inspection. EVIDENCE: COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39 and 42 Service users and staff benefit from clear leadership and good management by a competent registered manager. The provider supports a quality assurance system although the reintroduction of internal monitoring of the homes procedures and records by the manager is recommended. The wide varieties of health & safety records viewed were complete. Further work to ensure records relating to temperatures of serving hot foods and a regular review of safe working practise risk assessments in line with good practise are undertaken. EVIDENCE: A significant proportion of the inspection was spent with the registered manager. During this time the ethos of the service provision was described and examples of strategies and good practise for meeting assessed needs were seen in every day use. It was clear that the manager communicates a clear sense of direction to the staff evidenced through staff discussion. The provider organisation supports a quality assurance system to seek the views of service users and their representatives. There are monthly meetings for service users from each home, and some of these records were examined. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 18 Lay monitors, which are relatives of service users, also come and inspect the home and the latest report for this year was viewed. Further monitoring of reviewing advocacy services was also seen to be in progress with service users. The manager had developed an internal audit tool for sampling the quality of records and procedures within the home. These had not been completed during the manager’s absence and had not been resumed on her return. It would also benefit if this system were rolled out to both sites. Records were examined containing information for safe working practises. Health & safety records were examined and the wide varieties of records viewed were complete. Records seen included accident reporting, infection control, water temperature monitoring, fire safety, safe storage of hazardous substances and equipment maintenance logs. It was noted in Copper beech that the temperature when serving hot food had not been recorded since April 2005. Risk assessment seen to support safe working practises within the home were comprehensive and detailed, however those seen at Copper Beech had not been reviewed since March 2004. Requirements surrounding these findings have been made. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 4 x 3 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 COPPER BEECH SERVICES Score x x x x Standard No 37 38 39 40 41 42 43 Score x 4 2 x x 2 x H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13 Requirement The registered manager takes steps to ensure a record of temperature when serving hot food is maintained. The registered manager ensures that risk assessments supporting safe working practises are kept under review. Timescale for action 31/10/05 2. YA42 13 31/10/05 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. Refer to Standard YA22 YA24 YA39 Good Practice Recommendations That the manager ensures the outcome of formal complaints are recorded in line with the Providers complaints policy. That an action plan is produced outlining areas requiring redecoration and refurbishment of Copper Beech. That the manager re-introduces the use of the internal audit tool in both sites to ensure the quality of records and procedures are regularly monitored. COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI COPPER BEECH SERVICES H52-H01 S33966 Copper Beach Services V252438 230805 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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