Inspection on 24/01/06 for Copper Beech Services

This inspection was carried out on 24th January 2006.

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 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 Stewart Mynott Unannounced Inspection 24th January 2006 10:30 Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 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.V277829.R01.S.doc Version 5.1 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.V277829.R01.S.doc Version 5.1 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 Norwood Ravenswood T/A Norwood ***Post Vacant*** Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 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 previously 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, and 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 DS0000033966.V277829.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection occurring during the weekday lasting for six hours in duration. The purpose of this visit was to examine the arrangements for personal and healthcare needs of the service users, the lifestyle and daily routines and the staffing arrangements for the service. The majority of this inspection was spent in the “annex”. During this time the majority of staff on duty and service users were spoken to and observations were made into lifestyle and daily routines. Most of the service users were unable to directly give their views to the inspector in regards to the service, however through time spent in the home and observing behaviour, body language and staff interactions a general view could be gained. Time as also spent with the newly appointed manager at both sites and the service manager to discuss and evaluate this service. During the limited time at “Copper Beech” three staff were spoken to and some healthcare and lifestyle standards were crosschecked. Records in relation to the care of the service users were examined at both sites. What the service does well: What has improved since the last inspection? The service has recruited a new manager for the service to provide support and development of the service. The previously registered manager has now commenced a new role to include development and review of the lifestyle and daily routines for service users (particularly in Copper Beech) to further develop this service in line with current and new practises. An action plan has been identified by the new manager following an audit of the service arranged by the service manager. Supervision of staff is now to occur on a regular basis. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 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 the following standard(s): Standards 1 to 5 were not assessed during this inspection. EVIDENCE: Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 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 the following standard(s): Standards 6 to 10 were not assessed during this inspection. EVIDENCE: Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16 and 17 Service users have the opportunity to choose from a wide range of appropriate activities and leisure pursuits both within the village and wider community in accordance with individual needs and requirements. Daily routines and house rules promote independence, individual choice and freedom of movement, subject to any restrictions agreed in the individual plan. Service users are offered a varied and culturally appropriate menu. EVIDENCE: Staff discussed the arrangements for activities and leisure for service users. The village now has two “lifestyle opportunity managers” who have produced information about activities and pursuits both within the village and the Thames Valley region. This information was available in the home and provides an extensive list to provide a wide range of choice and opportunity. Senior team members (with the support of key workers) have the responsibility of assisting service users to choose an activity that they prefer and enjoy. Service users nominate their chosen activity on an application form, which the registered manager passes to the lifestyle managers, who check Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 11 availability and book places as required. In the Annex service users timetable demonstrated a good range of activities and leisure pursuits. In the morning of the inspection service users undertook activities as listed on their schedule. The daily schedule for the two service users supported in their own flat and service users at “Copper Beech” have more detailed daily programs to include time planned from rising to bed time with some activities provided within the home according to identified specific needs. During the inspection the atmosphere was calm and organised with service users and staff arriving and leaving at various times to attend organised activities. It was observed that service users were free to move around the home with staff supervising and providing support as required. Staff interacted with service users in a professional manner with an emphasis on service users choice, which was demonstrated throughout the inspection. Daily routines and house rules promote independence, individual choice and freedom of movement, subject to any restrictions agreed in the individual plan. Staff support service users maintain links with family and friends to include visits to spend time with family members. The menu at the Annex is coordinated by one of the support workers who described choosing the menu each week. The menu for the week was varied and support workers take responsibility for preparing each meal. A support worker prepared mushroom pasta for lunch during the inspection; the service users subsequently enjoyed this. Staff confirmed that they have attended cultural training and both the menu and food preparing is checked on a regular basis to ensure all cultural observances are strictly followed. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 18, 19 and 20 Service users are provided with flexible personal support to meet their needs and preferences. Some service users have a more detailed support plan in accordance with their needs. Service users physical and emotional healthcare needs are met. A review to include when service users last benefited from an eye examination is required. Service users benefit from safe and protective systems with appropriate policy and procedures in relation to medication needs. EVIDENCE: Personal care plans and preferred routines over a 24-hour period for most service users in the Annex were viewed. These contained detailed information in regards to the type of personal support and preferences on how this is delivered to include likes and dislikes. Individual daily records demonstrated flexibility and choice. Service users wishes on how they are supported with personal care and what they wear are respected. Service users can go to bed and get up when they wish. Daily records note all personal care and support, daily activity and meals taken over a 24-hour period. Records also demonstrate access to receive additional, specialist support and advice as needed from physiotherapists, psychiatrists, speech therapists and others. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 13 All service users have key workers who are responsible for updating plans and reviewing needs. It was noted that this is not occurring consistently for all service users at present. The new manager was aware of this issue. The healthcare arrangements for four service users living at the “annex” were examined. Records in the “key file” were examined and contained information about health appointments. Service users had access to local NHS healthcare facilities and routine screening as well as more specialist input such as psychiatrist support. The records seen did not record any routine optician visits or eye tests to ensure health needs are being met in this area. Staff spoken to were not aware of any recent visits. It is a requirement that a review is completed for all service users to determine when this last occurred and any necessary action is taken following this review. The systems for ordering, administration and returning medicines were explored with staff at “Copper Beech”. The home currently uses the NOMAD system. The medication charts were examined for all service users and contain useful information about how medication is to be administered and the side effects of each medicine. All medicines are administered with a witness and both staff initials recorded. The signatures/initials on the NOMAD sheets were not always decipherable, and it is advised to keep an easily accessible record of all specimen signatures and initials for reference. Medications not within cassettes are in addition counted with a witness on each occasion on administration and recorded on a separate “stock control” sheet. All staff receive medication training at induction. Training records for those staff on duty confirmed that they had received appropriate training. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 14 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 the following standard(s): Standards 22 and 23 were not assessed during this inspection. EVIDENCE: Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 15 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 the following standard(s): Standards 24 to 30 were not assessed during this inspection. EVIDENCE: Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Service users clearly benefit from being supported by a team that are available in sufficient numbers, have received a wide range of appropriate training and collectively have the qualities and competence to support their assessed needs. Service users are protected by the provider’s robust recruitment and selection procedure, which ensure staff suitability and fitness. Staffs now receive the appropriate level of supervision to ensure their ongoing monitoring and support. EVIDENCE: During the inspection staff were observed interacting with service users. All staff were able to communicate effectively with service users and were warm and friendly demonstrating a good understanding of each service users individual needs. Staff spoken to had a good understanding of the cultural needs of service users and felt supported in this area through ongoing training about festivals and access to the cultural advisor. Staffs supporting service users in both sites were attentive and comfortable with service users. Service users were clearly relaxed and at ease with staff and able to communicate their needs. The inspector was informed that there is currently 31 staff (excluding the manager), which work a range of hours. From records examined 16 staff hold Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 17 an NVQ with a further 11 working towards this qualification. The ratio of qualified staff has met the 50 ratio. Staff spoken to on duty felt there were enough staff available to fully meet service users needs. Rotas for the Annex were viewed and during the day seven staff are on duty to include a 2:1 ratio of staff for two service users that occupy their individual flats (within the Annex). This staffing level had been maintained within the last month. Some agency staff are used to cover for short term absences. Staff at both sites confirmed that there are regular staff meeting, which have been led by the new manager. Records relating to these meetings were viewed and signed by each staff member. There have been three meetings in the past two months. The supervision arrangements at the home were explored. Last year the recommended frequency of supervision had not been achieved as evidenced in staffs individual training records. The new manager has ensured that supervision sessions have been resumed. Staffs at the home have received training to ensure they understand the benefits of supervision. Supervisors have also received training in this area. Records for the staff on duty reveal that they had received an annual appraisal to review their performance and agree development plans for the coming year. The recruitment is carefully coordinated within the village following a robust recruitment and selection policy and procedure. Staff spoken to recollected this process to include interviews and written assessments. Two personnel files were examined for staff commencing employment within the last year. These contained all relevant pre employment checks necessary to ensure the suitability and fitness of new staff to ensure the ongoing protection of service users. Staff spoken to without exception felt they have received a good range of training to ensure they are able to carry out their function. The training records for those staff on duty in the Annex were examined and each contained an “individual staff member training record” listing courses and qualifications completed with the relevant certificates. From these records and staff discussions it is evident that they have completed mandatory topics, specialist courses to ensure they have the relevant skills particularly surrounding communication and autism and training to ensure an understanding of the Jewish faith. Two staff spoken to who have been employed for about a year recollected their induction and subsequent foundation training at the home. Their induction included an eight-day period of courses during the first six weeks. Their induction and foundation records were seen and completed appropriately. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 41 Service users will now benefit from a new manager in post to coordinate the service. Some of the records at the home will benefit from further review to ensure a consistent quality is maintained. EVIDENCE: A new manager has been appointed to manage the service who has been in post nearly two months. The manager is experienced and qualified and currently being supported by the service manager during his induction period. The service manager confirmed that an application for registration of the manager with the CSCI is about to be submitted. Staff spoken to were positive about the new manager describing him as approachable. Many staff confirmed that they had received a supervision session with the new manager and that staff meetings had taken place, which is helping the team to become familiar with the new manager. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 19 The previous registered manager has changed her role to become the “practise coordinator”. This role will involve the further development to care practises and specialist needs to include communication, day services and daily routines. Records relating to the care of service users are in place. The quality of some of the records examined, particularly those in the “key files” varied. This included partially incomplete records and information that is not current. The manager is introducing a system for key worker to provide monthly review summaries, which may assist in ensuring a consistent standard of record keeping in key files. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 20 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 X X 2 X X Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 21 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 YA19 Regulation 13 (1)(b) Requirement Timescale for action 30/04/06 2. YA41 17 The registered persons ensure that a review is completed to determine when all service users last benefited from an eye examination and any necessary action is taken following this review. The registered person ensure 30/04/06 that there is a consistent quality and approach to record keeping in relation to maintaining service users “key files” to include relevant and up to date information being provided for all service users. Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 22 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 YA18 Good Practice Recommendations The registered person should implement a consistent approach to ensure all service users receive “key worker reviews” at the same frequency in line with the Providers own procedures. The registered persons should consider maintaining a separate and accessible record specimen of staff signatures and initials to identify those recorded on service users medication administration sheets. 2 YA20 Copper Beech Services DS0000033966.V277829.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks 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 DS0000033966.V277829.R01.S.doc Version 5.1 Page 24 - 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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