Inspection on 17/01/07 for Copperbeech

This inspection was carried out on 17th January 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 found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copperbeech 08/08/08

Copperbeech 21/09/07

Copperbeech 30/01/06

Copperbeech 24/08/05

Copperbeech 23/02/05

Copperbeech 07/09/04

Copperbeech 02/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Copperbeech 23 Copperbeech Drive Balsall Heath Birmingham West Midlands B12 8SN Lead Inspector Key Unannounced Inspection 17th January 2007 10:00 Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Copperbeech Address 23 Copperbeech Drive Balsall Heath Birmingham West Midlands B12 8SN 0121 440 8419 0121 440 8419 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) londonroad@tiscali.co.uk Milbury Care Services Limited Focus Housing Association Miss Kim Jacqueline Powell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years with a learning disability. The home may accommodate two named service users over the age of 65 with a learning disability. The home must periodically review that it can still meet the needs of the named service users over 65, and a record of these reviews must be retained in the home. That the manager completes training in Protection of Vulnerable Adults by 31st October 2006. 30th January 2006 4. Date of last inspection Brief Description of the Service: 23 Copperbeech Drive is registered to provide accommodation, care and support for four adults with learning disabilities. The Home is run by Milbury Care Services. The property is a two-storey house in a residential development in the Balsall Heath area of Birmingham.Accommodation. There are four single bedrooms, one of which is on the ground floor. Downstairs there is also the domestic scale kitchen, separate laundry, lounge, conservatory dining room and an assisted bathroom / w.c. Upstairs are three bedrooms, another bathroom / w.c., and the staff sleep-in room, which is also used as a small office. To the rear of the house is a secure small garden, and there is a paved area at the front of the property with limited off-road parking.There is a range of shops and community facilities close by, and the area is well served by public transport. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day by one inspector from 10 a.m – 5.30pm. All 4 residents were seen, two spoken to at length, two did not have verbal communication but routines and observations of interactions and discussions with staff provided a view of their care. A pre-inspection questionnaire was provided by the Manager on the day of inspection and provides a basis of some information in this report. Feedback forms for residents, relatives and professionals were not supplied by CSCI prior to the inspection consequently there was no written feedback. All staff on duty were spoken to and provided helpful and useful information about resident care and the routines of the home. There was an inspection of the environment including all bedrooms. Records relating to the inspection process were seen and included: care plans, risk assessments, medication records, fire records, health & safety records etc. What the service does well: There is a domestic style environment providing a family setting. This is a pleasant and welcoming environment. The home caters for a wide age range but there is good integration in the home. Residents use their bedrooms throughout the day as they wish there is total flexibility. Two younger residents attend college courses regularly several times each week. There is a programme of daytime activity for all residents. Residents benefit from a good standard of personal care Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care planning now needs to be consolidated not extended to provide an easily accessed plan of care to inform staff concisely of how residents needs can be met. There are daytime activities for residents but access to community activities needs to be developed further this should include social and recreational groups where residents have the opportunity to develop personal relationships. It is important that all residents have an annual health check. Suitable scales should be purchased to allow important monitoring of weight loss. The furniture in the lounge area is old, worn, broken and unsuitable, new furniture must be provided as planned. Statutory training for new and existing staff should be provided as outlined in the training development plan. COSHH cupboard must be kept locked at all times. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 7 A pillow sensor fire alert should be provided for resident identified. 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. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was evidence of adequate information to make an informed choice about the home. Pre-admissions procedures had secured appropriate introductions and pre-admission assessment. EVIDENCE: Individual assessment information is incorporated into care plan and provides basis for the plans. This was a requirement of the last report and is met. There is a statement of purpose/service users guide in place and available for prospective residents. A new resident has been admitted since the last inspection. Procedures, documentation and care plan were inspected in relation that that admission. The resident came from another home within the Milbury Group. Care planning information had been transferred from the former home, although this did need some updating/review relevant to the new environment. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 10 Prior to the admission the person spent several days at Copperbeech for lunch, dinner and also an overnight stay. There were exceptionally detailed records of each visit with outcomes. The person was seen and assessed in the previous setting by Copperbeech staff and the transition carried out allowing assessment and choice. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Progress has been good in the development of care plans and risk assessments. Review and consolidation of information is now the focus to provide a clear, concise current plan of care which is more user friendly. EVIDENCE: Previous requirements have been made to provide additional information and develop care plans and risk assessments. These requirements have been met. A lot of work has been done in this area. The home should now concentrate upon updating all information and presenting it in a more useable format as a current working document so that staff can use it as a plan of clear and useful instruction of the actions required to meet needs. Presently is sits as a formidable document of considerable information which is neither user friendly or easily referenced. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 12 Some information had not been updated for example use of walking frame and assistance from staff was recorded for mobility needs – relevant only when resident had fractured hip. She is now independently mobile. In relation to a recently admitted resident a personal fire risk assessment included provision of a pillow sensor (he has no hearing), this has not been brought from the previous placement and should be provided. Aspects of care plans were numbered, as were risk assessments – one relating to the other. In one instance seen a resident had 16 separate risk assessments which were cross referenced to the care plan and had been reviewed regularly. Care plans are reviewed on a 3 monthly basis with Key Worker and Manager. Reviews also provide the time and opportunity to review all care planning information and ensure is still relevant and to change/update that information as required. The only additional information that is required in care plans is to provide a simple, concise night care plan which can be readily used by night staff and any bank or agency staff covering night time shifts. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11 – 16 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Opportunities to develop external social and community activities should be explored to further enhance the quality of life of residents. EVIDENCE: These standards were not inspected at the time of the last inspection. A requirement of the previous report to evaluate activities to improve the range, frequency and quality of opportunities available was repeated. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 14 This has been addressed in part - There is now a diary for each resident, completed daily giving details of the events and activities of the day. These are completed daily and give adequate information. Opportunities for residents to engage in local, social and community activities are limited. There is an outline programme of internal and external activities - Two younger residents attend college courses on 2 and 3 days per week respectively. Another resident attends a day centre on 2 days, the other resident no longer wishes to attend day centre services and goes shopping, out for lunch etc. This is quite a diverse resident group – two residents are over 75 years, two are under 56 years. Two have no speech, two have had falls with serious consequences and also have mental health needs. None of the residents are able to go out alone, staff escort required at all times. There are reported to be adequate arrangements for transport two can use public transport and staff cars and taxis are available and used. There is a fund of £38 per week for each resident for transport expenses. There are the usual indoor activities which seem piecemeal including bingo, draughts, snakes/ladders and some art-type activities. When asked what she does at weekends a resident said “watch films and TV”. There appear limited evening or weekend activities. Residents do not belong to external social groups (disability or non-disability). This is an area that could be developed. The Manager agreed with this during discussions and will consult both residents and staff about options to extend social and community contacts. Family contacts are also diverse. One resident has twice-yearly visits, one has irregular visits but some telephone contact. Two residents have more frequent family visits and also go home to relatives. Most relatives respond to request to attend reviews. Staff do positively promote family contact wherever possible. There are reported to be regular residents meetings and 1:1 discussions. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 – 21 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some aspects of healthcare and support were good but there are some gaps. It is important to closely monitor some aspects of healthcare. There was a very positive example of early referral to GP with improved health as a result. EVIDENCE: At the time of the last inspection there had been a change from one person sleeping-in on call to provision of a waking night worker. This followed 2 residents having falls and having post-operative/hospital care needs. The waking night provision continues and is permanent. There has been some loss of confidence by a resident following a fall and considerable psychological support is needed. She no longer has confidence to use the assisted bathing facilities and prefers to have thorough wash in her bedroom. She is supported in her choice. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 16 Two residents without speech are assisted with Makaton, gestures and signs. Observations showed a positive input from staff and also responses. Two residents have diagnosed mental health needs, one has regular intramuscular injections by the CPN. It was interesting that the behaviour of this resident had been noted to have changed dramatically, she had little movitation, reduced appetite and communication diminished dramatically. Staff consulted the GP - depression diagnosed, medication prescribed and the result is return to normal behaviour with much improved motivation and generally improved physical and mental health and quality of life. One resident has a constant low weight/food intake. Addressed in care plan with instructions that GP consulted if weight falls below 6 stones. She is currently 6 stones – although records showed a wide variation in weight (clearly incorrect) – she is weighed weekly and over a recent 3 week period weight recorded : 6st 5 lbs, 6st, 6.st.5lbs. - This persons weight must be monitored accurately on a weekly basis and to facilitate this a requirement is made to provide suitable, accurate and reliable scales for that purpose. – The recording of daily intake of food/drink for this resident was good and wellquantified. Recording of health issues were generally good a referral for specialist assessment to Gastroenterologist and Orthopaedic Consultant had been monitored and recorded with outcomes. In relation to a recently admitted resident records showed that he had attended a well-man clinic in August 2005 and a further health check was required. It is important that annual health checks are carried out for all residents on at least an annual basis. Inspection of records showed referral to assessment by Speech Therapist had been initiated by the home in September 2006 but no appointment made. The home will pursue the matter. At the time of the last inspection there were some shortcomings in the medication system, this included paracetamol non-prescribed for communal use, no count of medication to audit the system and PRN protocols not dated/reviewed. These matters have been addressed and some improvements made. On this visit the medication file which contains details of all medication prescribed including the purpose and side-effects was not accurate, some medication had been changed/withdrawn and the list should be updated. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 17 Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedures and adult protection procedures have been tested since the last inspection and found to be robust and satisfactory. EVIDENCE: There is a satisfactory complaints procedure in place for residents and visitors. Two complaints made by residents since the last inspection have been referred under Vulnerable Adults procedures by staff. This also resulted in an internal investigation concerning a staff member. The outcomes are completed and recorded. A member of staff no longer works as the home as a result. A requirement of the last inspection to provide training for staff in Vulnerable Adults procedures has been met. All employed staff have now received this training. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 - 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A generally well-presented environment but some areas require refurbishment. EVIDENCE: The home presents as a domestic style environment. Is pleasant and homely. On the ground floor there is a lounge area, conservatory – used for dining or activity purposes, spacious well-equipped kitchen, laundry, assisted bathroom with toilet and one bedroom. On the first floor there are 3 bedrooms, assisted bathroom and small office (formerly sleeping-in room). Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 20 The ground floor bedroom is smaller than the other bedrooms. Presently it will not adequately house the residents clothing and possessions. Clothing is piled around the room not allowing use of chair or some drawers. This room is being fitted with new bedroom furniture, paid for by the resident, who has been “saving up” but very enthusiastic about the refitting of her bedroom. This was scheduled to take place in the week following the inspection. She uses the room considerably during the day and this was evident during the day of inspection. The ground floor bathroom is of good size, domestic in style and conducive with encouragement to use it in a relaxing way. There is a good assisted facility. It was noted that a pot used to secure urine sample previously was still in the bathroom, this should be removed in the interests of infection control. The toilet seat requires replacement and one is apparently on order. The lounge area is adequate in size but the furniture requires complete replacement. Many items were broken and unsuitable. This is apparently in process and swift replacement needed. The laundry area is small but adequate and domestic in style. It was concerning to see the COSHH cupboard was unlocked in this room. There is an assisted bathroom on the first floor and shower facility. Bedrooms on the first floor were spacious and well personalised, reflecting the individual interests of residents. Those residents who showed the inspector their bedrooms clearly had pride in ownership. It was noted in a first floor bedroom that a wardrobe with a top-box was not fixed to the wall and the top-box seemed unstable. This should be secured to the wall in the interests of safety. It was noted that there was no chair in this bedroom although it was a large room and there was adequate space. The resident sat on the bed but there was no space for visitors to sit. Two residents have had injuries from falls and some handrails had been fitted to parts of the ground floor stair area. An Occupational Therapist has carried out an assessment and additional rails etc. required. This is apparently in discussions at this time with the providers and the Housing Association who own the building. There is a private garden area to the rear with good access from the building and used considerably during the summer months. The standards of cleanliness throughout the home were high. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 21 Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37 – 39, 41,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There has been improvements in the areas of staff recruitment procedures and supervision. Agency staff are now rarely used. Bank staff and the homes staff are being used to cover staff on leave providing continuity. Some areas of statutory training are required. EVIDENCE: There have been concerns in the recent past about excessive use of agency staff. This has been resolved with appointment/availability of the homes/Milbury bank staff. Several shifts are covered each week by bank staff but they have knowledge of the home and individual residents. Existing staff cover a large number of vacant shifts wherever possible. The use of bank staff is required because there are presently 2 support worker vacancies ( appointments made and commencement of duties soon) and also Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 23 the fact that 3 staff are presently on maternity leave – one due to return in February 2007. There are a total of 270 staffing hours per week – this includes 197 hours for days and 73 hours for nights. There was previously only 1 staff sleeping in but this has now changed to 1 waking night support worker due to increased dependency of residents. There is presently only 1 member of staff (apart from Manger) NVQ qualified, although two others are studying NVQ3 and one due for completion soon. It is important to register new staff and those returning from maternity leave on NVQ training courses as soon as possible. Training provided for staff at Copperbeech Drive over the past year includes: Healthy eating, fire awareness, epilepsy, moving & handling, first aid, health & Safety, adult protection and autism. Other areas of statutory training have been identified and requested from the providers for new and some existing staff. This will be carried out as outlined in the Training & Development Plan for the home . Staff files were inspected and all required recruitment procedures seen to be followed satisfactorily. All required documentation under schedule 2 was present. Staff supervision has been established for all staff as required in the last inspection report. All staff receive supervision at least 6 times per year. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is now a Registered Manager who provides a positive lead in the home. A quality assurance report allows resident input. The home is run in the best interests of residents. Some aspects of safety require action. EVIDENCE: A requirement of the last report to produce a report of quality assurance monitoring has been done. This was seen and included resident views and inputs. A requirement to send a copy of the 5 year electrical hard-wiring certificate to CSCI has also been done. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 25 The present Registered Manager was approved by CSCI in August 2006. A condition of her registration was made for her to complete training the Protection of Vulnerable Adults by 31st October 2006. This condition has been met. The Manager has completed the required NVQ4 training and awaiting approval to complete the Registered Managers Award soon. The Manager was present for this inspection. She interacted easily with both residents and staff. There seemed an open atmosphere in the home where residents and staff were able to discuss any matter. The home appeared well managed and run. Fire records were seen and checks of equipment carried out at the required intervals. One resident was able to demonstrate what action she would take in the event of fire and clearly been involved in fire drills and discussions about fire safety. It was seen from the notes of a resident admitted from another service that he had a pillow-sensor fire alert in the previous placement but his had not been brought to Copperbeech. This resident has virtually no hearing and no speech. A risk assessment is required at this time but provision of sensor as previously provided must be considered. During the inspection it was noted for a time that the COSHH cupboard, located in the laundry area was unlocked (key in lock). A requirement is made that the COSHH cupboard must be kept locked at all times to ensure safety of residents. It was noted that the cupboard contained bleach which the Manager said was used for floor cleaning. It was suggested that an alternative product could be one of the proprietary brands of sanitizer that are potentially less harmful. A wardrobe in a first floor bedroom identified was not fixed to the wall and had a top-box which appeared unsafe when opening the wardrobe door. This should be secured to the wall to ensure safety. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 2 14 2 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 3 3 X 3 2 x Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15(2) Requirement Consolidate care planning information to provide a current concise and easily identifiable plan of care. Enable residents to engage in local, social and community activities. Previous timescale not met. All residents must have annual health check. Audiology & other tests where appropriate must be arranged. Provide suitable scales to ensure accurate weekly monitoring of weight. Complete replacement of furniture in lounge area is required. Remove pot from bathroom and replace toilet seat. Complete statutory training for all new & existing staff as outlined in the homes training development plan. Provide pillow sensor fire alert for resident identified and provide risk assessment. COSHH cupboard must be kept locked at all times. Wardrobe in bedroom identified DS0000016887.V325724.R01.S.doc Timescale for action 31/03/07 2 YA13 16(2)(m) 31/03/07 3 YA19 12(1)(a) 28/02/07 4 5 6 7 YA19 YA24 YA30 YA32 12(1)(a) 23(2)(a) 13(3) 18(1)(c ) 28/02/07 28/02/07 31/01/07 30/04/07 8 9 10 YA42 YA42 YA42 23(4)(a) 13(4)(a) 13(4) 31/01/07 18/01/07 25/01/07 Page 28 Copperbeech Version 5.2 to be fixed to wall to ensure 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. 1 2 Refer to Standard YA19 YA29 Good Practice Recommendations Follow up required for referral to Speech Therapist made in September 2006 for resident identified. Monitor progress of discussions between providers and property owners concerning fitting of handrails advised by OT. Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Copperbeech DS0000016887.V325724.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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