Inspection on 29/05/07 for Copper Beeches

This inspection was carried out on 29th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Copper Beeches 10/11/06

Copper Beeches 08/11/05

Copper Beeches 10/05/05

Copper Beeches 09/12/04

Copper Beeches 21/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Copper Beeches Woodlands Way London Road Andover Hants SP10 2QU Lead Inspector Beverley Rand Unannounced Inspection 29th May 2007 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Copper Beeches Address Woodlands Way London Road Andover Hants SP10 2QU 01264 353703 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) glynis.addington@hants.gov.uk Hampshire County Council To be confirmed Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42) of places Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2006 Brief Description of the Service: Copper Beeches is a local authority residential home, registered for forty two service users in the categories of old age, not falling within any other category, and dementia care for service users over the age of sixty five. The home is situated in a quiet residential area of Andover, within easy reach of local amenities. Accommodation is arranged on two floors, with passenger lift access. Since the last inspection the home has admitted more residents with dementia. There are two five bedded ‘units’ or ‘flats’ which although still part of the home, are self contained. Existing residents who are more independent and do not have needs associated with dementia live in these flats. The current fees are £446 a week. This information was provided on the day of the inspection. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. Prior to the inspection, the inspector reviewed the last inspection report, four comment cards and the Annual Quality Assurance Assessment, (AQAA). During the inspection the inspector looked around the home, spoke with four residents, two visitors, two staff and the acting manager. What the service does well: What has improved since the last inspection? What they could do better: Medication records must not have gaps: they must be accurate to ensure residents are not put at risk. Staff and managers need to be more alert to when an abusive incident may have happened and follow procedures accordingly. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to Copper Beeches. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from having their needs assessed prior to admission. EVIDENCE: The Annual Quality Assurance Assessment, (AQAA) details how the home undertakes pre-admission assessments. The manager looks at the professional assessments already in place and visits the person at home or in hospital. The potential resident and their family, if appropriate, are invited to spend a day at the home to look around and meet staff and other residents. The home uses this day assessment to ensure they can meet the person’s needs and so the person can decide if they like the home. The inspector looked at three preadmission assessments and these held all the necessary information. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from care plans being in place and being able to access healthcare professionals. The home ensures that residents are treated with respect. Records of medication administered are not sufficiently robust to ensure residents are protected. EVIDENCE: All residents have a care plan which details preferences regarding personal care as well as strategies to meet individual needs such as waking and getting up during the night. Care plans are reviewed monthly. The inspector spoke with two staff about the care needs of three residents and they were consistent in their ways of working with the care plan. One section in the residents’ files is used to monitor and record the health needs of each person. These were up-to-date and demonstrated that healthcare needs were regularly monitored. Where concerns about healthcare needs had been identified, there were records of the follow up action that had Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 10 been taken. Residents have access to healthcare professionals such as GPs, district nurses, chiropodists and so on. On the day of the inspection the optician was visiting to undertake eye tests for some residents. Staff gave examples as to how they respected residents’ privacy and dignity, such as knocking on bedroom doors before entering and closing curtains. Residents agreed that staff were polite and respectful to them. The home has procedures in place to cover the administration of medication and storage of medication was appropriate. There is a photograph of each resident on the administration record sheet which is considered good practice. However, the inspector looked at three individual records and found each one had gaps in the recording of medication given. Gaps were also found on other records for which there was no explanation. Gaps in recording mean that it is not possible to know whether a resident took their medication or not. Only the deputy managers administer medication and they have all received appropriate training. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being able to take part in activities and enjoying their meals. Residents were able to exercise control over their own lives and were supported to maintain contact with friends and relatives. EVIDENCE: On the day of the inspection the staff team had organised quizzes for small groups of residents in different areas of the main lounge. Staff were also observed stopping to chat with residents. Staff said activities included baking cakes, games, ball games and drawing as well as visiting entertainers. The home employs two staff to co-ordinate activities and staff said that activities boards are displayed in the ‘units’ and everyone was welcome to join in. Residents spoken with said they had no complaints about daily routines or activities. A visitor said they saw a lot of activities going on and that entertainers went all around the home to ensure residents did not miss out if they were sat away from the main area. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 12 A visitor confirmed that they were able to visit every day and were made welcome. The home has quiet areas where residents can see their visitors in private if they wish. Residents can make every day decisions such as what to wear and whether to be involved in activities. There was evidence around the home that residents had brought in their own furniture and ornaments. Residents spoken with liked the food, one describing it as, ‘splendid’. A small issue regarding vegetables was raised with the inspector and the cook and acting manager agreed to look into this. The cooks provide all the meals and cook food from scratch, such as cakes and pies. Residents were supported with equipment such as lipped plates to enable them to be as independent as possible. Staff told the inspector how they supported residents whose eating abilities varied on a daily basis which also promotes their independence. Daily menus, with choices, were displayed and food is pureed if necessary. A breakfast board showed that bacon sandwiches had been available on the morning of the inspection. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that residents feel able to complain. Adult protection procedures are in place and staff have been trained but one recorded incident showed that residents may not be protected from abuse. EVIDENCE: The home’s complaints procedure is displayed in the three areas of the home and there have not been any complaints since the last inspection. Residents felt able to raise complaints and the inspector was told of two small issues which they had raised and which were dealt with straight away. Staff confirmed it was a resident’s right to complain and what action they would take if residents raised a complaint with them. There are procedures in place regarding safeguarding adults and staff spoken with were aware of what they should do if there was an allegation or suspicion of abuse but were less clear about the procedures which would then be followed, or the involvement and role of the local authority adult services. The acting manager agreed to address this with staff to further ensure residents safety. Existing staff have received basic training in adult protection and there is a programme in place for new staff to undergo training. However, the inspector became aware of a recent incident which may have put a resident at risk of abuse. The acting manager was not aware of any further action being taken to protect residents and had not considered that the incident should Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 14 have been investigated further. Through discussion with the acting manager and staff it was evident they were aware as to what abuse was and would have reported anything they had known to have happened. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well decorated and clean home. EVIDENCE: The communal space is well decorated and furnished, with the lounge area being divided into smaller sitting areas. Bedrooms were also well decorated and residents had personalised them with ornaments and pictures. The home has big, pictorial signs indicating the toilets and communal rooms and bedroom doors have the name of the resident and their key worker to assist residents in finding their way around the home independently. One bedroom has recently been converted to an office as the view was limited to looking over another part of the roof. The home has a shop, a private telephone room and a hairdressing room which can also be used for visiting healthcare professionals. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 16 The inspector found the bathrooms were clean and there were a number of pieces of bathing equipment but felt there was a lack of any homely touches. The acting manager agreed to consider how the bathrooms may be made more homely. All rooms have call bells which residents said they used to call staff. The acting manager said that she has considered the accessibility of the call bells as referred to in the last inspection report, and residents can now reach the bells from their beds or chairs. Staff felt many residents are unable to use call bells due to their level of dementia. The home has a courtyard garden with seating and plants. Decorations have been added in the form of large ladybirds and butterflies. As the home has admitted more residents with dementia, the inspector asked the acting manager to consider the impact of such large insects on confused people who may also have hallucinations. The acting manager agreed to consider this with respect to the current and future residents. The home employs two cleaning staff in the morning and one in the afternoon throughout the week and this was evident through the cleanliness of the home. Residents and visitors confirmed the home was always clean. There are two sluice rooms which were kept locked and the laundry was well organised. Staff were aware of procedures to follow to prevent cross infection such as using protective gloves and aprons. Specific bags are used for soiled laundry. The last inspection report said that light pulls in bathrooms and toilets needed replacing. The acting manager has purchased new light pulls but had not put them in place due to being unsure about what was expected and whether they were good enough. The inspector felt they would be appropriate and the acting manager agreed to put them in place as soon as possible. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being supported by sufficient, well-trained staff and are protected by the home’s recruitment policies and practices. EVIDENCE: The home has a rolling two week rota which generally includes six care staff, one assistant manager, the acting manager, domestic, cooking and laundry staff. The domestic staff work shifts both morning and afternoon, seven days a week. There are two cooks and a kitchen assistant who produce all meals. A staff member is employed to undertake laundry tasks forty hours a week. Residents and visitors spoke highly of the staff. The home is committed to staff training and qualifications. The home employs 37 care staff and of these 19 have achieved the National Vocational Qualification in care, (NVQ) level 2 or above. Two are currently working towards it. New staff are recruited using a robust recruitment procedure. The inspector looked at three recruitment files for new staff and found that they all contained the necessary information, which had been received before the person started work. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 18 There is a formal induction for new staff. Ongoing training includes Adult Protection, Food Hygiene, Challenging Behaviour, Working with People with Dementia and Equality and Diversity, for which records were available. As the home is admitting more people with dementia, care staff undertake a four day training course on Working with People with Dementia. Domiciliary support staff have undertaken a one day Dementia Awareness course and this is seen as good practice. Since the last inspection nineteen staff have undertaken training in dealing with incidents of difficult behaviour and it is planned that the rest will do this. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ financial interests are safeguarded and their views regarding the home are sought. Residents are protected by maintenance of equipment. EVIDENCE: There is not currently a registered manager in post but the acting manager has applied to be registered. The acting manager was the registered manager of another home for two and a half years and has had about twenty years experience in the care sector. She also has the NVQ4 in care and the Registered Manager’s Award. The home has implemented a formal quality assurance system in the last twelve months. The AQAA states that the home does well with regard to Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 20 sending and acting upon surveys sent to residents and relatives. However, the acting manager has plans to further develop this and keep relatives more informed. The home holds a residents’ meeting every three months or more frequently for the residents in the upstairs unit. A staff member brought the minutes of one such meeting to a resident whilst the inspector was there. The minutes are then displayed on the wall. The last report was displayed in the main hallway for anyone to look at. The home looks after money on behalf of some residents. The inspector looked at three records and found they matched the amount of money being looked after. Certificates were available for maintenance and repair of equipment such as the hoists. Staff have received regular training on fire safety and with regard to a new fire safety system in the home. Food was appropriately stored in the kitchen. Work place risk assessments were being audited monthly. Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 3 X 3 X X 3 Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 22 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 2 Standard OP9 OP18 Regulation 13 (2) 13 (6) Requirement Timescale for action 30/06/07 Medication records must be completed to minimise the risk of administration error. Adult protection procedures must 30/06/07 be followed where a risk of abuse is identified to ensure residents’ safety. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Copper Beeches DS0000037292.V336244.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Beeches DS0000037292.V336244.R01.S.doc Version 5.2 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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