Inspection on 21/09/07 for Copperbeech

This inspection was carried out on 21st September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copperbeech 08/08/08

Copperbeech 17/01/07

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 Donna Ahern Key Unannounced Inspection 21st September 2007 12:45 Copperbeech DS0000016887.V348953.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.V348953.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.V348953.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 Ltd Focus Housing Association Miss Kim Jacqueline Powell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Copperbeech DS0000016887.V348953.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. 17th January 2007 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. 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. At the time of the visit copies of the service user guide did not have full details of the fee level of the home only peoples contributions were detailed. CSCI reports were available in the Home. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care inspection (CSCI) is based upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that needs further development. The inspection took place over one day; the Home did not know we were coming. The inspector met people living at the Home, spent time observing support and interactions from staff, had a tour of the premises including peoples bedrooms, looked at care records and health care records and medication management. Health and safety records and staffing records were also assessed. All information looked at was used to determine whether peoples varied needs are being effectively met. Two people were identified for close examination this included reading their care plans, risk assessments daily records and other relevant information. This is part of a process known as “case tracking” where evidence is matched to outcomes for service users. What the service does well: What has improved since the last inspection? New sofas have been provided in the lounge so that people have a comfortable place to sit. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 6 All people living in the home have had an annual health check so that they receive the medical in put they require. Suitable weighing scales have been provided so that peoples weight can be properly monitored and any early signs of health concerns can be monitored. A sensor fire alert has been provided for one of the people with sensory impairment so they can be alerted in the event of the fire alarm sounding to protect their safety. What they could do better: Care plans should be further developed so that there is a clear and concise plan in place informing staff how best to meet people’s needs. Risk assessments for the support people need from night staff should be completed so that any known risk are identified and planned for including how and why night staff checks people. This information should be recorded within the persons care plan. Advice should be sought on managing pressures areas so that any risks to people are well managed. Health action plans should be completed in full so that each person’s health care needs can be monitored. It was recommended that a log of complaints is kept this will provide an audit trail of information and evidence that all complaints received have been dealt with. The outcome of the Occupational Therapy assessment is required and should be followed up so that people’s safety is promoted and protected. The storage cupboard in the lounge is damaged and requires replacement so that it is safe. Service user meetings should be developed so that there is evidence that issues raised by people in the home have been followed through. Staff members require some training updates so that they have the required skills and knowledge to meet peoples assessed needs. The consent to receive medication of people living in the home should be sought and recorded in their care plan. The fire procedure, which tells people what to do if the fire alarm sounds required updating as it still, referred to sleep in staff at night. This must detail the required procedure so that people are supported to evacuate safely. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 7 A fire risk assessment was in place however it was unclear when this was last reviewed this must be completed to ensure fire safety is well managed. The arrangements for accident and incident reporting must be improved so that CSCI are informed of incidents in the home. 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.V348953.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.V348953.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home or choosing whether or not to live there have the information so they know what the home provides and how their needs will be met there. EVIDENCE: The Statement of Purpose and Service User Guide were looked at and describe the services and facilities provided in the home. Information has been produced in an easy read format making it more accessible for some of the people who live at the home. The fee level for the home only included people’s contributions on individual peoples copy of their service user guide and the fee information needs to be completed for one of the people living in the home. There have been no new people admitted to the home since the last inspection so it was not possible to assess this standard in full. The previous inspection found procedures and documentation in place to be satisfactory. The previous inspection report identified that care plan information required some updating for a person who had been admitted from another Millbury home, this was still work in progress as raised under outcome area individual needs and Choices. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 10 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): 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. Further development of care plans and behaviour management plans would provide staff with the information they need to know to meet peoples assessed needs. EVIDENCE: Two peoples care plans were looked at for the purpose of this inspection. Care plans contained a lot of information and generally set out the care to be carried out by staff and included information on the persons likes and dislikes, health needs, personal care, culture and preferences. Because of the amount of information on peoples care file it was difficult to know what information is really important and it was also difficult to find particular information quickly. The manager said that in the week following the inspection new care plan formats are to be introduced and all four care plans will be reviewed. This should be a really positive development and hopefully the outcome will be a Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 11 person centred care plan that states how people want their needs to be met and provides staff with the information they need to know to meet peoples assessed needs. The previous inspection required that nighttime care plans were developed for each person these had been completed and ensure peoples receive the support they require at night from night staff. However the care plan must be underpinned by a risk assessment so that any known risk are identified and planned for including how and why night staff checks people this information should be recorded within the persons care plan. Behaviour guidelines need some further development so that they clearly state how to support people safely, the reviews of these should ensure that strategies in place are still appropriate. A number of risk assessments are in place it is advised that when reviewing the risk assessments there should be evidence that any incidents in relation to the risk assessment are evaluated and that the strategies in place are still relevant. Choices and decision-making are restricted to day-to-day things such as what to eat, drink, and whether to take part in activities such as doing puzzles, listening to music, going for a walk. Two of the people have limited communication and two of the people were only able to give very limited views of the service. Staff observed made some attempts to offer basic choices such as offering tabletop activities and sitting alongside people to support and interact. People were seen to move freely around the home and had full access to their own bedroom. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Further development of activities and opportunities to go out should be explored so that all people living in the home are supported to engage in activities that meet their individual needs. EVIDENCE: This is quite a diverse resident group – two people are over 75 years, two are under 56 years. Two people have no verbal communication; two people have had falls with serious consequences and also have mental health needs. None of the people are able to go out alone; staff escort is required at all times. There are reported to be adequate arrangements for transport two people can use public transport and staff cars and taxis are available and used. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 13 There are some indoor activities including puzzles and, draughts, and some art-type activities which people were supported to use during the visit. Two of the people were supported to go out on the day of the visit, one person went to have a manicure and one person went food shopping. Activity records were looked at and indicate that people are supported to go out for occasional meals out, walks to Moseley Village, bowling and shopping however there were limited evening or weekend activities. People living in the home do not belong to external social groups (disability or non-disability). Previous reports have raised the need to develop this area. The manager feels some progress has been made and said there will be further developments so that all people living in the home are supported to engage in activities that meet their individual needs. It was advised that the records for evaluating activities are used more effectively by staff to record people’s response to activities and any learning points this information can then be put to good use when planning future activities Family contacts is variable. One person 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. People spoken with said they have been on lots of different holidays, which they have enjoyed. Menus are completed weekly; those sampled were varied and culturally appropriate. The evening meal was observed. Sufficient staff were available to assist people with their meal. It was positive that staff ate with people living in the home and saw this as a social occasion, appropriate support was offered. One of the people living in the home choose to eat at a different time to the other people this was respected and the person was supported to do as they choose. There were adequate supplies of food in the home including fresh fruit and snacks and drinks. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are well supported to meet their personal care needs. Arrangements in place are not sufficient to ensure that people’s healthcare needs are fully met. EVIDENCE: Care plans had details of how people should be supported with their personal care. As previously mentioned in this report the care plans would benefit from some development so that information is easy to follow so people receive the support they need. The manager confirmed that this should be addressed with the redevelopment of people care plans, which was due to take place the end of September 2007. The previous inspection report reported on the change in nighttime staffing arrangements from one-person sleeping-in on call to provision of a waking night worker. This followed two people living in the home having falls and having post-operative/hospital care needs. The waking night provision continues and is permanent. As previously raised in this report the nighttime support people receive must be supported with a risk assessment for each Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 15 person so that people are supported from staff in a safe way that meets their assessed needs. People who live in the home had been supported to dress appropriately to their age, gender, the weather and the activities they were doing this indicates that people receive good support from staff. Two people with no verbal communication are assisted with gestures and signs. Observations during the visit were generally positive from staff on duty. Two people have diagnosed mental health needs; one has regular intramuscular injections by the CPN. One person has a constant low weight/food intake, which is closely monitored by staff, with instructions that the GP is consulted if their weight falls below a specific weight. The previous report required that suitable, accurate and reliable scales were available to ensure accurate monitoring for that purpose these were available. It is advised that a referral is made to speech and language therapy for this person to eliminate any potential swallowing difficulties such as dysphasia. One of the people has a very low body weight and also spends periods of the day lying down. A referral should made to the tissue viability nurse for advice and support and a risk assessment should be completed so that any risks to pressure area break down are monitored and any aids to reduce the risk of pressure sores provided. Each person has a health action plan this is an individual plan of what the person needs to do to stay healthy. Health action plans looked at were incomplete and did not include health concerns that had been identified within peoples care plans this has the potential to cause inconsistencies in the monitoring of the persons health care and the support given by staff. The medication administration records were looked at and had been signed appropriately to show that people had received the medication they need. It was advised during the visit that when people are prescribed additional medication that is added mid cycle to the MAR sheet, this information should be checked and witnessed by a second person to minimise any errors being made and to ensure an audit trail of prescribed medication is available. The consent to receive medication of people living in the home should be sought and recorded in their care plan. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home are listened to and their views acted upon. Arrangements are generally sufficient to ensure that people living in the home are protected from abuse. EVIDENCE: No complaints had been received by CSCI since the last key inspection. The owner had not received any complaints since the last inspection. The complaints procedure if followed would ensure concerns raised were dealt with. It was recommended that a log of complaints is kept this will provide an audit trail of information and evidence that all complaints received have been dealt with. Due to their complex needs some of the people who live at the home would find it difficult to make a complaint and therefore are reliant on staff, relatives or an advocate to act on their behalf. However as raised in the previous inspection report concerns raised by one of the people living in the home were listened to and acted on appropriately. Staff are trained in adult protection and the prevention of abuse so they know what to do if there are allegations of abuse and how to stop abuse happening. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 17 The policy on abuse and whistle blowing policy was available in the office for staff to refer to. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 18 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): 24 and 30 Quality in this outcome area is. Adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable. The outcome of an assessment of the environment remains outstanding and could put people at risk. EVIDENCE: 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). The ground floor bedroom is smaller than the other bedrooms. The ground floor bathroom has an assisted facility. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 19 The lounge area is adequate in size and new sofas had just been provided which really improved the comfort for people. The storage cupboard is damaged and requires replacement so it is safe. The laundry area is small but adequate and domestic in style. The COSHH cupboard was locked ensuring peoples safety. 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 people. Two people 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 several months ago however the outcome of this remains outstanding. The manager agreed to follow this up and act upon any advice given. Satisfactory infection control procedures were in place. The home was clean and free from unpleasant odour. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 20 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): 32, 33,34,35 and 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate to meet people’s needs. Robust recruitment procedures protect the people living in the home. Staff training updates in mandatory areas will ensure that suitably trained staff supports people living in the home. EVIDENCE: Previous inspection reports raised some concern about the high use of agency staff. This has improved with permanent staff employed to vacant posts. The manager was in the process of appointing two night staff in the interim permanent staff were doing overtime so a consistent service is provided. During the visit staff interacted with people living in the home in a friendly and respectful manner. Two support workers and the manager were on duty, Staffing levels were adequate to meet people’s individual needs. Two staff recruitment files were examined completed application form, references, criminal bureau checks and training details were all on file Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 21 indicating that robust recruitment procedures are in place to protect the people living in the home. Induction details were on staff files. The Manager was in the process of ensuring staff are put forward for training up-dates in mandatory areas including health and safety, food hygiene, adult protection and infection control so staff have the required skills and knowledge to support people. The manager said that an NVQ assessor is due to commence soon and staff would then be supported to complete NVQ level 2 in care. It is advised that the manager completes training on the new Mental capacity Act so that she is fully aware of issues of consent and the implications of how the new Act will protect the financial, healthcare and legal rights of people living in the home. Staff supervision schedules were looked at and indicated these take place every few months, these are one-one sessions with the manager and provide an opportunity to look at work practice issues and training and development of individual staff members. The minutes seen of staff meetings indicate that meetings are infrequent it is advised these are re-established on a regular basis so staff know how to meet individual needs and are aware of any changes in the home. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 22 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): 37, 39, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure that the people living in the home generally benefit from a well run home. Arrangements in place for the management of health and safety do not fully ensure that the health and safety of people living in the home is promoted and protected. EVIDENCE: The Manager was approved by CSCI in August 2006. She has completed the required NVQ4 training and is in the process of doing complete the Registered Managers Award. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 23 The manager facilitated the inspection process and was open and welcoming and informed the inspector of relevant information. She interacted well with people living in the home and staff on duty. Good progress had been made on previous requirements indicating compliance with the regulations and a commitment to improve the Home for the benefit of the people who live there. There are a number of health care issues that do require follow up as detailed in the health and personal care section of the report. It is of some concern that the managers is only allocated 15 hours management time and is expected to work 21 hours on shift. It is recommended that this be reviewed so that there is adequate management time allocated for the manager to fulfil her duties. The manager was in the process of reorganising the office so that information is accessible and a working area is provided for staff. Policies and Procedures were available in the main office so that staff has access to relevant guidance promoting the best interest of people living in the home. Fire tests and servicing had been undertaken as required. The fire procedure required updating as it still referred to sleep in staff at night. This must detail the required procedure so that people are supported to evacuate safely. The electrical and gas supply had been serviced and tested as required and maintained so they are safe. A fire risk assessment was in place however it was unclear when this was last reviewed this must be completed to ensure fire safety is well managed. It was advised when general risk assessments are reviewed, this process should identify that the control factors are still relevant. Accident and incident reporting and recording required some attention not all accidents recorded in the accident book had been reported to CSCI as required. The recording and logging systems in place required some attention so it is clear what needs to be reported, who it is reported to and where this information is recorded for reference and to provide a clear audit trail of information. The paper work seen of routine serving of some of the moving and handling equipment identified that some follow up work to maintain this equipment safely was required. The previous inspection report confirmed that progress had been made on implementing a quality assurance system. It was recommended that minutes of meetings held with the people living in the home to ask their views on dayto –day matters were developed so that there is evidence that requests made by people have been listened to and followed through. The owner does regular monthly audits of the home to ensure the home is managed appropriately and copies of these reports were available. Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 2 X 2 X Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 25 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 YA9 Regulation 13 (4) a, b, c Requirement Timescale for action 31/10/07 2 YA19 12 1 (a, b) 3 YA19 12 1 (a, b) 4 YA19 12 1 (a, b) Risk assessments for the support people need from night staff should be completed so that any known risk are identified and planned for. A referral should made to the 31/10/07 tissue viability nurse for advice and support on tissue viability and any aids to reduce the risk of pressure sores provided. A risk assessment on tissue 31/10/07 viability should be completed so any potential risks to people living in the home are well managed. Health action plans were 30/11/07 incomplete and did not include health concerns that had been identified within peoples care plans. These should be completed as this has the potential to cause inconsistencies in the monitoring of peoples health care and the support given by staff. The outcome of the Occupational Therapy assessment is required and should be followed up so that people’s safety is DS0000016887.V348953.R01.S.doc 5 YA29 23 (2) n 31/10/07 Copperbeech Version 5.2 Page 26 paramount. 6 YA35 18(1)(c) Some mandatory training required updating so staff have the required skills and knowledge to support people. The arrangements in place for the recording and reporting of accidents and incidents required review to ensure notifiable incidents are reported as required. 31/12/07 7 YA40 Schedule 4 17 (2) 12 31/10/07 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 YA1 YA6 Good Practice Recommendations Fee levels should be in peoples service user guide so they know what the fee is and what it includes. Further development of care plans and behaviour management plans is required so that staff have the information they need to know to meet peoples assessed needs. Behaviour guidelines need some further development so that they clearly state the support required to support people safely, and reviews of these should ensure that strategies in place are still appropriate. A number of risk assessments are in place it is advised that when reviewing the risk assessments there should be evidence that any incidents in relation to the risk assessment are evaluated and that the strategies in place are still relevant. Further development of activities and opportunities to go out should be explored so that all people living in the home are supported to engage in activities that meet their individual needs. The records for evaluating activities could be used more effectively by staff to record people’s response to activities and any learning points. This information can then be put DS0000016887.V348953.R01.S.doc Version 5.2 Page 27 3 YA7 4 YA9 5 YA12 6 YA13 Copperbeech 7 8 9 10 11 12 YA19 YA20 YA20 YA22 YA24 YA35 13 YA33 to good use when planning future activities. It is advised that a referral is made to speech and language therapy for this person to eliminate any potential swallowing difficulties such as dysphasia. When additions are made to Medication record sheet mid cycle these should be witnessed and signed to minimise errors and to provide an audit trail. People’s consent to receive medication should be sought and recorded in their care plan. It was recommended that a log of complaints is kept this will provide an audit trail of information and evidence that all complaints received have been dealt with. The storage cupboard in the lounge is damaged and requires replacement so that it is safe. It is advised that the manager completes training on the new Mental capacity Act so that she is fully aware of issues of consent and the implications of how the new Act will protect the financial, healthcare and legal rights of people living in the home. Staff meetings should be re-established on a regular basis so staff know how to meet individual needs and are aware of any changes in the home. It is recommended that the allocated management hours be reviewed to ensure that there are adequate management hours. The fire procedure required updating as it still referred to sleep in staff at night. This must detail the required procedure so that people are supported to evacuate safely. The fire risk assessment was in place however it was unclear when this was last reviewed. This must be kept under review to ensure the safety of people living in the home. It was advised when general risk assessments are reviewed, this process should identify that the control factors are still relevant. Service user meetings should be developed so that there is evidence that issues raised by people in the home have been followed through. Follow up action must be taken on the recommendations of the servicing of equipment to ensure equipment is safe to use. 14 15 16 YA37 YA42 YA42 17 18 19 YA42 YA39 YA42 Copperbeech DS0000016887.V348953.R01.S.doc Version 5.2 Page 28 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. 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