Inspection on 27/01/06 for Copperbeech

This inspection was carried out on 27th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copperbeech 09/10/07

Copperbeech 09/11/06

Copperbeech 12/09/05

Copperbeech 16/03/05

Copperbeech 18/11/04

Copperbeech 23/03/04

Copperbeech 02/12/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Copperbeech (Amber Project) 172 Heanor Road Smalley Derby Derbyshire DE7 6DY Lead Inspector Anthony Barker Unannounced Inspection 27th January 2006 09:20 Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 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 DS0000019964.V273813.R01.S.doc Version 5.0 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 DS0000019964.V273813.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Copperbeech Address 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) (Amber Project) 172 Heanor Road Smalley Derby Derbyshire DE7 6DY (01773) 530937 (01773) 530937 None United Response Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: Copperbeach is a detached house situated on a main road within reasonable distance of the town of Heanor. Service users are provided with good-sized accommodation and single rooms. There is a good-sized rear garden. The Home offers personal and social care to people with a severe learning disability with associated conditions that may include autism, sensory disability or challenging behaviour. Activities are planned to meet individual needs. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 5 hours and was a routine unannounced inspection. The last inspection took place in September 2005 and was an unannounced inspection. The Acting Manager was spoken to and records were inspected. There was no tour of the premises on this occasion. One service user’s records were examined as part of the case tracking method. Service users’ learning disabilities were such that they were unable to speak except on a single word level. The inspector met two service users. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Details of contracting arrangements between the purchasing authority and United Response must be kept at the Home. Service users’ care plans must cover all aspects of personal, social and healthcare needs. Handwritten entries on the Medication Administration Record sheets must be signed, countersigned and dated. Certain maintenance and refurbishment issues are still outstanding and the lounge must be made more comfortable and homely. At least half of the care staff group must achieve a National Vocational Qualification (NVQ) in care at level 2. All records specified in Schedule 4 of the Regulations must be available for inspection at all times and all those staff who work both day and Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 6 night shifts must receive fire training sessions at a frequency of at least twice a year. The views of service users, family, friends and others involved in the service users’ lives must be sought regarding the quality of service provided. 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 Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 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 DS0000019964.V273813.R01.S.doc Version 5.0 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 the following standard(s): 1&5 Information about the Home was available in order for prospective service users and their families to make an informed choice about where to live. Current service users were also benefiting from this information. Each service user had a written contract with the Home specifying the terms and conditions of their residence but there were no contracts with the purchasing agencies. EVIDENCE: The Home’s Statement of Purpose had been improved to to reflect the changes to management arrangements and to show that the Home’s physical environment is compliant with the NMS. The Acting Manager stated that all items listed in Schedule 1 of the Regulations were now in place. The Service Users’ Guide was seen to include details of how to contact the local Social Services Dept and local Health Authority. The Acting Manager said that service users’ families had received a copy of the Guide. The Home provided a complete statement of terms and conditions/contract for each service user, included in the service users’ guide. This statement had been personalised to the Home but was awaiting the inclusion of staff photographs. There were still no details of the contracting arrangements between purchasing agencies and United Response, in respect of the three service users, although there was written evidence that these had been sought. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 The risks to which service users were exposed, along with comprehensive plans to manage these risks, were recorded. However, a limited number of service users’ needs and personal goals were reflected in the individual care plans. EVIDENCE: Care plans, risk assessments and Behaviour Management Plans were comprehensive and were being reviewed every six months or sooner if pertinent changes occur. These documents were helpfully guiding staff in their interactions with service users but they did not reflect their broad ranging needs. The Acting Manager showed that she was aware of the need to provide more holistic care plans. The preferred name of the service user and name of the keyworker had been recorded and a review of care planning documentation, with a view to editing any unneeded or repetitive documentation, had been started but not completed, the Acting Manager explained. The front information sheet did not include statements about elements of the NMS that had not been carried out due to unsuitability or service user incapacity. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 11 There was an extensive range of risk assessments recorded with regard to each service user. The Acting Manager spoke of plans to rationalise and reduce the number of risk assessments. Those on the case-tracked service user’s file had mainly only dates recorded to indicate a review – very few had associated comments. The Acting Manager spoke of plans to address this. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 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 the following standard(s): Service users’ responsibility for housekeeping tasks was specified in the Service Users’ Guide. EVIDENCE: The housekeeping tasks expected of service users were being recorded in the Service Users’ Guide to the Home, as previously recommended. Other aspects of standard 16, and this section, were not assessed on this occasion. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users were not being fully protected by the Home’s policies and procedures for dealing with medicines although significant improvements had been made since the last inspection. EVIDENCE: Medicines were being stored in a new dedicated cabinet. The Medication Administration Record (MAR) sheets relating to the case-tracked service user was examined. It was confusing for the reader to follow changes in medication and in MAR sheet. There were letters, on file, confirming medication changes. However, handwritten entries made when medication doses had changed had no associated signature, date or counter-signature. All items of medication administered to service users were being recorded on the front of the MAR sheets. The instructions for the administration of occasional medicines (PRN) were clearly documented, signed and dated. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users were benefiting from a clear and effective complaints procedure. They were being protected from abuse by a robust set of Adult Protection procedures although certain training needs were apparent. EVIDENCE: The Home’s written complaints procedure and complaints record form were examined and found to be satisfactory. The Acting Manager reported there had been no recent complaints. She said that she and the other staff make informal concerns known within the staff group, on behalf of individual service users, in order to maintain good standards of care. The Home had an extensive written policy and procedure on prevention of abuse linked to the statutory procedures and prepared by United Response. There was also a copy of the Derbyshire policy and procedure although the Derbyshire Report forms could not be found. The Acting Manager had received Adult Protection training by Derbyshire Social Services although some years ago. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Service users were living in a generally safe environment. However, it was not homely everywhere and there was need for repairs and refurbishment. Service users’ needs were being addressed in their bedrooms. The Home was clean and hygienic although there was potential for some hygiene problems. EVIDENCE: Material conditions were generally satisfactory within the Home except that the main lounge carpet was still very dirty in front of the settee and needed replacement. Also, there was still damaged plasterwork on the first floor landing. The lounge looked somewhat bare with just one small picture displayed on the white painted walls. The Acting Manager stated that the whole premises were being refurbished and re-decorated during the first week in February 2006 and all the above issues would be addressed then. All service users were provided with suitable furniture in their bedrooms and all had a lockable space. None of the bedroom doors were lockable and there were no wash hand basins in any bedroom. However, service users’ care plans contained reasons why it was inappropriate for each of them to hold keys to their bedroom doors and the provision of wash hand basins had been reconsidered and conclusions reached that these would be a hazard to service Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 16 users and the environment. One bedroom had a carpet that was discoloured around its edge. The Home was clean and free from odours. There were hand drying facilities and toilet tissue in the bathroom and toilets. As at the last inspection, neither of the WC seats stayed upright which could potentially cause problems for the three male service users and compromise hygiene. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 & 35 Service users’ need for staff to be clear about their roles and responsibilities was being addressed. Service users were not benefiting from an adequately qualified staff group although their needs were being met by staff who were generally well-trained. They were being protected by the Home’s recruitment procedures. EVIDENCE: The Acting Manager spoke of having identified a number of needs within the staff team. A skills audit had been carried out and staff had asked for clarification of their roles and responsibilities and had requested team-building opportunities. In response to this a joint team meeting had been held with the Home’s staff and the manager and staff from another, nearby, United Response care home. Topics covered had included United Response’s Mission Statement and its values, job descriptions, key worker roles, communication and perceptions and boundaries and routines for service users. The Acting Manager stated that these issues had been, and were continuing to be, reinforced at subsequent team meetings and staff supervision sessions. The Acting Manager was still the only member of staff with a National Vocational Qualification (NVQ). Staff files were available at this inspection. However, on one staff file examined there was no recruitment information and the Acting Manager said Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 18 that this would be held at the United Response Area Office. The other staff file examined was satisfactory with regard to recruitment information. The staff training matrix record was examined. It was noted that no staff had been provided with fire training since April 2004 and some staff had received their last fire training earlier than this date. The Acting Manager said she was aware of the need to provide fire training every six months to staff who work night shifts. All other training matters were satisfactory and it was noted that a wide range of staff training was planned for the first three months of 2006. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Service users were starting to benefit from the management approach of the Home. The views expressed by, or on behalf of, service users were not underpinning review of the Home’s services. EVIDENCE: There was evidence at this inspection of good progress on meeting requirements and recommendations since the last inspection. The Acting Manager was working closely with the manager of another, nearby, United Response care home and both were recorded on the Home’s Manager Availability Chart. A good level of communication between the two managers was observed. Other aspects of standard 38 were not assessed on this occasion. The Home’s quality assurance measures comprised a draft annual service plan for 2005/6 and Annual Service User Financial Plan; the Active Support Audit; quarterly Health & Safety audit and the Annual Service Audit. The Home was not formally seeking the views of service users - through independent advocates, for example - or of family, friends or others involved in the service Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 20 users’ lives regarding the quality of service provided. The Acting Manager showed good awareness of what was needed to improve standards within the service. Efforts had been made to reduce the potential risk inherent in the use of multipoint adapters in single power sockets in bedrooms. These adaptors had been replaced with multi-point blocks. Other aspects of standard 42 were not assessed on this occasion. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 21 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 3 X X X 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X 2 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Copperbeech Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000019964.V273813.R01.S.doc Version 5.0 Page 22 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 YA5 Regulation 5(3) Requirement Details of contracting arrangements (between the purchasing authority and provider) must be kept at the Home and be available for inspection. (Previous timescale was 31/10/03) Service users’ care plans must be holistic - covering all aspects of personal, social and healthcare needs - with associated goals. Handwritten entries on the Medication Administration Record sheets must be signed, countersigned and dated. The registered person must replace the carpet in the main lounge.(Previous timescale was 30/6/05) The registered person must arrange for repairs to be made to the damaged plasterwork on the first floor landing.(Previous timescale was 30/6/05) The lounge must be made more comfortable and homely. (Previous timescale was 01/01/06) The bedroom carpet, identified in DS0000019964.V273813.R01.S.doc Timescale for action 01/05/06 2 YA6 15(1) 01/05/06 3 YA20 13(2) 01/03/06 4 YA24 16(2)(c) 01/04/06 5 YA24 23(2)(b) 01/04/06 6 YA24 23(2)(a) 01/04/06 7 YA26 16(2)(c) 01/04/06 Page 23 Copperbeech Version 5.0 8 9 YA32 YA34 18(1)(a) 17(3)(b) 10 YA35 23(4)(d) 11 YA39 24(1) this report, must be cleaned or replaced. (Previous timescale 01/02/06 - had not expired) At least 50 of the care staff must achieve an NVQ in care at level 2. All records specified in Schedule 4 of the Regulations must be available for inspection at all times. (Previous timescale was 01/11/05) The registered person must provide all those staff who work both day and night shifts with fire training sessions at a frequency of at least twice a year. The registered person must formally seek the views of service users, family, friends and others involved in the service users’ lives regarding the quality of service provided. 01/07/06 01/03/06 01/05/06 01/07/06 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 YA5 Good Practice Recommendations The copies of the individual statement of terms and conditions of residence, included in the service users’ guide, should be signed on behalf of individuals and given to them with the complete document.(This was a recommendation from 18/11/04) The front information sheet should include statements about elements of the NMS that have not been carried out due to unsuitability or service user incapacity.(This was a recommendation from 18/11/04) The registered person should complete a review of care planning documentation and edit any unneeded or repetitive documentation.(This was a recommendation from 18/11/04) Risk assessments, as well as other recorded service user DS0000019964.V273813.R01.S.doc Version 5.0 Page 24 2 YA6 3 YA6 4 YA9 Copperbeech 5 6 7 8 9 YA20 YA23 YA23 YA30 YA31 plans, should be reviewed and comments recorded. The process by which changes to medication are recorded on MAR sheets must be reviewed so as to maintain a clear set of records. The Home should ensure that the Derbyshire Report forms are immediately to hand should an incident of Adult Protection need to be communicated to Social Services. The Acting Manager should be provided with a refresher course of Adult Protection training by Derbyshire Social Services. The problem of the WC seats not staying upright should be addressed.(This was a recommendation from 12/09/05) The Acting Manager should continue to ensure that staff understand their own and others roles and responsibilities. Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Copperbeech DS0000019964.V273813.R01.S.doc Version 5.0 Page 26 - 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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