CARE HOME ADULTS 18-65
Copperbeech 75-76 Penkett Road Wallasey Wirral CH45 7QG Lead Inspector
Inger Moynihan Unannounced 15 September 2005 9:30 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. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Copperbeech Address 75-76 Penkett Road Wallasey Wirral CH45 7QG 0151 639 1405 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) Mannacom Ltd Mrs Karen Scregg, acting manager CRH 25 Category(ies) of MD - 25 registration, with number of places Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 2 named service users over 65 years of age (MD/E) within the overall total of 25 Date of last inspection 15 March 2005 Brief Description of the Service: Copperbeech is a large three storey detached property that was registered in February 1991 for the care of people with mental health problems. It is situated in an urban location within easy reach of Liscard and New Brighton town centres which both have a selection of shops, banks and community facilities. The area in which the home is situated contains many other residential homes providing care for other vulnerable groups of people.The home is situated in its own grounds with parking space for about six cars. There is a large garden at the back of the home with a patio. Accommodation is provided in 14 single and 3 shared bedrooms all with en-suite facilities. Three flats in the basement provide more independent accommodation. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 5.5 hours and was the statutory announced inspection for 2005/2006. A tour of the premises took place and staff and service users records were inspected. Five staff and six service users were spoken to during this inspection. What the service does well:
Service users’ care needs are assessed before they move into the home to ensure the staff team can provide the required care. A plan of the care provided to each service user has been drawn up. This provides staff with the information they need on how to meet service users needs. Service users are encouraged to take risks in order to maintain their independence, although at the same time systems are in place to ensure their safety and welfare. Service users are supported to participate in the local community through the use of healthcare and leisure facilities. The routines within the home are flexible which promotes service users independence and choice and ensures their rights and responsibilities are respected. Service users health care needs are well met with evidence of good multidisciplinary working taking place. Thorough medication administration procedures are in place to ensure service users good health and well being. The home has a comprehensive complaints procedure to ensure service users views are listened to and acted upon. Systems are in place to ensure service users are safeguarded from abuse and harm. There are robust procedures for the recruitment of staff which safeguards and protects service users living at the home. Staff have undertaken a range of training which enables them to care for the service users in line with their particular requirements. Staff have a positive attitude towards, their comments included I love coming to work and I feel we work well as a team. This was further supported by another is member of staff who stated after a period of change I feel everything has settle down very well and I enjoy coming to work.
Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 6 There are clear lines of management and accountability within the home which is run for service users bet interest. Quality assurance systems are in place to ensure a high standard care is maintained and the health, safety and welfare of the service users is well promoted throughout the home. Discussion with both staff and service confirmed the acting manager, Mrs Karen Scregg was very popular member of staff with everyone commenting on her friendly and supportive manner. One member of staff stated she is an obvious choice for the role of manager and another member of staff stating she does a great job and is extremely supportive. What has improved since the last inspection? What they could do better:
During inspection each of the service users commented they did not enjoy the meals provided although they did confirm they had sufficient to eat and a choice was always available. This issue was raised with the registered providers who confirmed the matter was already being addressed. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 7 The standard of the decor is mixed with some parts of the home being maintained to a good standard and other parts remaining in need of further redecoration and refurbishment . The registered persons demonstrated a commitment to improving the standard of the facilities. 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. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 Service users’ care needs are assessed before they move into the home to ensure the registered persons and staff team can provide the required care. EVIDENCE: Documentation examined indicated that a comprehensive assessment of service users care needs has been carried out to ensure the staff at the home are able to support the service users in accordance with their particular needs. While there is a large amount of documentation relating to the assessment process, the registered providers confirmed the system in place is effective and staff are up to date on service users care needs. A discussion took place with the registered providers around some of the language used in this documentation as it appeared rather out of date. In light of this the registered providers must ensure all staff are clear on the meaning of all language used in any documentation that care staff have access to. Service users have access to a range of health care professionals to ensure their good physical and mental well-being. There is evidence of multidisciplinary working to ensure all aspects of service users care needs are addressed and met. A record of this information is kept to help staff monitor service users’ general welfare. This is further supported by a system whereby staff spend time each day discussing any issues or concerns that have arisen over the past 24 hours. Through discussion, the registered provider and acting manager demonstrated they met the service users’ physical and mental health needs in a variety of ways such as staff being provided with a range of
Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 10 appropriate training; a range of social activities being provided and staff being available for support when necessary. All of these factors contribute to providing a safe environment for service users to live. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 11 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 A plan of the care provided to each service user has been drawn up. This provides staff with the information they need on how to meet service users needs. Service users are encouraged to take risks in order to maintain their independence, although at the same time systems are in place to ensure their safety and welfare. EVIDENCE: A documented care plan is in place for each service users. The care plans cover a range of issues relating to service users’ care needs and give staff guidance on how to understand the service users often complex mental health needs and how to look after the service users in accordance with their individual requirements. The service users are encouraged to be a part of the care planning process and make decisions about their own development and plans for the future. They are also encouraged to take responsible risks as part of living an independent lifestyle although documented risk assessments have been compiled to ensure their safety. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 12 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) 14, 16 and 17 Service users are supported to participate in the local community through the use of healthcare and leisure facilities. The routines within the home are flexible which promotes service users independence and choice and ensures their rights and responsibilities are respected. A varied and balanced menu was in place however, all of the service users spoken to said they did not enjoy the meals. EVIDENCE: Service users are supported to make use of community facilities which goes some way to ensure they are accepted into the local community and not segregated because of their mental health problems. Service users are provided with a range of leisure facilities and make use of the local pubs, cinema and shops etc. Leisure activities are provided on an individual basis or within small groups with appropriate staff support being provided at all times. An activities organiser is also employed at the home on a part time basis. She will work with service users on an individual basis or in small groups on activities such as art, crafts, quizzes and gardening etc. The service users spoken to confirmed the routines in the home are flexible and they could come and go as they wished. This flexibility is an important
Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 13 aspect of care for people with mental health problems and ensures their independence and rights. The service users spoken to confirmed their relatives and friends could visit at any time which ensures friendships and personal relationships are maintained. A varied and balanced diet is provided to ensure service users interest and good health. Service users medical needs are included in the menu planning and staff work with service users on an individual basis around any medical requirements. Each of the service users spoken to during inspection commented they did not enjoy the meals although they did confirm a choice was always available. This issue was raised with the registered providers who confirmed the matter was already being addressed. The provision of enjoyable meals is vitally important for service users living within a residential setting as this not only provides interest at a key time of the day, but it also ensures good health and well-being. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 14 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) 19 and 20 Service users health care needs are well met with evidence of good multidisciplinary working taking place. Thorough medication administration procedures are in place to ensure service users good health and well being. EVIDENCE: Regular contact is made with a range of health care professionals who give advice and support as and when required. A record of service users general welfare is in place along with the outcome of any health care appointments. Senior members of staff are appropriately trained to care for specific aspects of service user care needs and guidelines are in place to support the staff on the action they should take if any concerns arise. All of this is in line with good practice and ensures service users physical and mental health is monitored and maintained. All of these factors contribute to providing a safe environment for service users to live. The systems in place for the administration of medication are good with all the required documentation being in place. Appropriate training has been provided to those staff who take responsibility for administering medication. Some service users take responsibility for their own medication which promotes and maintains their independence. A system is in place to ensure the medication is audited weekly. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 15 Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 16 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 The home has a comprehensive complaints procedure to ensure service users views are listened to and acted upon. Systems are in place to ensure service users are safeguarded from abuse and harm. EVIDENCE: The CSCI has not received any complaints about standard of care provided at Copperbeech. The registered persons confirmed they had not received any complaints. The complaints procedure is clearly displayed and the service users and staff spoken to were aware of the action they should take in the event of them receiving complaint. The service users spoken to during the inspection stated they were happy with the standard of care they received and had no complaints to make. Documentation is in place on the protection of vulnerable adults from abuse along with a copy of the Wirral Adult Protection Procedures. Staff spoken to demonstrated an understanding of what constitutes abuse and the action they should take if they knew or suspected an incident of abuse had occurred. All staff have completed training in this area of care although a refresher training course is planned for the near future. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 17 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 and 30 The standard of the decor is mixed with some parts of the home being maintained to a good standard and other parts being in need of further decoration and refurbishment . The home does not therefore present as a homely and comfortable environment throughout. The registered persons are committed to improving the standard of the facilities. EVIDENCE: Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 18 In October 2004 Copperbeech was sold and new providers took over the running of the home. Since this time the refurbishment of the building has continued and improvements have been made all round • • • • New furniture has been purchased new carpets and floor coverings have been fitted new televisions have been provided bathrooms and toilets have been redecorated. All of this redecoration work continues to have a positive impact upon the environment and contributes to providing a much more pleasant and comfortable place to live. The registered providers have worked extremely hard to improve the standard of the environment and have demonstrated a commitment to ensure any future developments are carried out and maintained to a high standard. All of the service users spoken to during inspection made positive comments about the improvements with one service user stating this feels like a real home now. Another service users stated the improvements are great, it is a much better home to live in now. Staff comments included it is a much nicer place to work now and I enjoy coming to work. The standard of hygiene throughout the building is good. The domestic staff spoken to during the inspection confirmed they have carried out appropriate training for their role and always had sufficient equipment and materials to carry out their work. They commented they enjoyed their work and found the new structures and systems very efficient. The standard of cleanliness in the kitchen was good. All of this contributes to a safe and comfortable environment for the service users to live. Arrangements are being made for the floor in the laundry to be replaced in the near future. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 19 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) 32, 33 and 34 There are robust procedures for the recruitment of staff which safeguards and protects service users living at the home. Staff have undertaken a range of training which enables them to care for the service users in accordance with their particular requirements. Staff are evenly deployed throughout the week and additional care staffing hours have been provided for those service users with high dependency needs. EVIDENCE: Staff records are up to date and thorough recruitment procedures are in place to ensure the staff at the home are suitably qualified and safe to work with vulnerable adults. Staff are evenly deployed throughout the week. A high dependency allowance is paid to the registered providers in respect of four service users who require additional support because of their increased care needs. The registered providers confirmed this allowance was being used to provide extra support by way of additional care staffing hours. The rota indicated the required care staffing hours are being provided. A Criminal Records Bureau check is carried out prior to any member of staff being employed at the home. The staff group is stable which is a positive aspect of the home as this provides consistency in the care provided and enables positive working relationships to develop. Staff spoken to stated a range of training is provided to support them within their
Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 20 role. There is a planned programme of training for the forthcoming year to ensure staff are suitably qualified and up to date with current good practice. Through discussion the staff demonstrated a positive attitude towards their work which contributes to providing a supportive and caring environment to service users who often experience very complex mental health problems; this is a very positive aspect of the home. Staff comments included I love coming to work and I feel we all work well as a team. This was further supported by another member of staff who stated after a period of change I feel everything has settle down very well and I enjoy coming to work. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 21 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) 37, 39 and 42 There are clear lines of management and accountability within the home which is run for service users best interest. Quality assurance systems are in place to ensure a high standard care is maintained and the health, safety and welfare of the service users is well promoted throughout the home. EVIDENCE: Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 22 There is currently no registered manager at Copperbeech although Mrs Karen Scregg is acting as manager and being supported by the two registered providers. Mrs Scregg is in the process of applying to the CSCI to become registered as manager for this service and has enrolled on the NVQ 4 to support her application. During the inspection Mrs Scregg demonstrated her understanding of the service users care needs and how she supports and manage the staff team. Discussion with both staff and service users confirmed Mrs Scregg was an extremely popular member of staff with everyone commenting on her supportive and friendly manner. One member of staff stated she is an obvious choice for the role of manager, another member of staff stated she does a great job and is extremely supportive. Effective quality assurance and monitoring systems are in place to ensure the home is run for service users best interest. Questionnaires have recently been given to service users to seek out their views on the standard of care they receive. For the most part of the comments were very positive and the registered providers were in the process of looking into any comments that needed addressing. Questionnaires will also be issued to staff in the near future for this purpose. Examination of documentation and discussion with the registered providers confirmed that service users health and safety is well promoted with safe working practices being implemented throughout the home. Staff are provided with appropriate training around this issue and regular fire safety checks and checks on all equipment are carried out. All of this ensure a safe environment is provided for the service users to live in and demonstrates the registered providers commitment to ensuring this aspect of service provision is taken very seriously. To further promote service users health and safety, the registered providers are advised to keep up to date with the information provided on the Health and Safety Executive website. Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 23 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 3 3 x x Standard No 22 23
ENVIRONMENT Score 3 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 x x x x 3 Standard No 11 12 13 14 15 16 17 x x x 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Copperbeech Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 24 yes 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 24 Regulation 23 Requirement The registered persons are required to ensure all parts of the building are maintained to a satisfactory standard Timescale for action 1/12/06 2. 3. 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 Good Practice Recommendations Copperbeech F52_F02_s62442_Copperbeech_v245785_150905_Stage_4.doc Version 1.40 Page 25 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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