CARE HOME ADULTS 18-65
Copperbeech 23 Copperbeech Drive Balsall Heath Birmingham West Midlands B12 8SN Lead Inspector
Gerard Hammond Unannounced Inspection 30th January 2006 12:25 Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 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.V281480.R01.S.doc Version 5.1 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.V281480.R01.S.doc Version 5.1 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 Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 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. 24th August 2005 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 is provided in 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/WC. Upstairs are three bedrooms, another bathroom/WC, and the staff sleep-in room, which is also used as a small office. To the rear of the house is 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 transportation. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection visit in the current year, and was unannounced. This report should be read in conjunction with the one written at the time of the previous inspection on 24 August 2005. The Inspector formally interviewed the Manager and met informally with two of the residents and two members of staff. Direct observation and sampling of records (including care plans, personal files, previous reports and safety records) were used for the purposes of compiling this report. A tour of the building was also completed. What the service does well: What has improved since the last inspection?
The overall position with regard to staffing the Home has improved since the last inspection. Previous reports highlighted issues relating to an overdependence on agency personnel. However, vacant posts have now been filled and this should have a positive effect on the provision and continuity of care. Waking night cover is currently being provided, in response to the changed care needs of one resident. Staff team meetings are now taking place on a regular basis, and formal supervision has also improved. The Manager is continuing in her efforts to improve the service for the benefit of the people living in the house as she grows in experience and personal professional development. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 7 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.V281480.R01.S.doc Version 5.1 Page 8 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): 2 Residents’ strengths and needs are assessed, and this information should now be used to support the review of individual care plans. EVIDENCE: Key Standard 2 was assessed at the last inspection, and a requirement made that residents’ strengths and needs assessments should be reviewed and updated. There is evidence on personal files of continuing work being done in this regard, for example completed Everyday Living Skills Inventories (ELSI). This information should now be summarised, so that each person has a clear statement of strengths and needs that can be appropriately considered at review. This is an essential component of the care management process, forming as it does the starting point of the required “assess – plan –review” cycle. However, the work that has been done should be acknowledged: what is required now is that the available information is brought together and presented in a more useable format. There have been no further admissions since the time of the last inspection. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 9 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 Individual plans require further development so as to reflect residents’ goals. This should be done in a way that makes it possible to measure whether or not goals have been achieved. Responsible risk taking is encouraged, but more work is needed to develop risk assessments appropriately. EVIDENCE: Key Standards 6, 7 and 9 were all assessed at the last inspection, with Standard 7 met in full. Work has been done to develop some of the detail contained in individual plans. Guidance about how people should be supported is now much clearer where this has been done, and this should be continued and completed. It was also noted that there are now clearer links between plans and risk assessments, and this too should be commended, and completed in all cases. It is recommended that each individual plan be numbered, so as to support complete cross-referencing. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 10 It was noted at the time of the last inspection that plans were in need of further development, so that they include individuals’ goals. It is important that set goals have outcomes that can be measured, and that these are appropriately evaluated when plans are reviewed. This should be at least every six months. A written record must be kept, indicating who takes part, and how decisions are made. Attention is drawn to the Home’s registration conditions in this regard. It is clear that residents’ changing care needs are being considered (e.g. new provision of waking night staff), but this should be formalised and recorded appropriately. Risk assessments were sample checked, and further work is required to ensure that hazards are identified correctly, and that appropriate control measures are included in individual plans. For example, one resident has a risk assessment of the hazards associated with over exposure to the sun. This indicates that she should not “sit in the sun too long”. The care plan should include specific guidance about the maximum length of time that should elapse before action needs to be taken. Similarly, another care plan included guidelines for ensuring that one residents’ room is free from food, but there was no associated risk assessment. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 11 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): EVIDENCE: Key Standards 12, 13, 15, 16 and 17 were all assessed at the last inspection. Standards 15, 16 and 17 were met in full, but requirements made with regard to Standards 12 and 13 remain outstanding. Residents’ activity programmes need to be reviewed and evaluated, so that improvements can be made to the range, quality and frequency of the opportunities currently available to each individual. This should be directly linked to each person’s assessed needs and identified goals. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 12 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 Policy, procedures and practice with regard to the storage, handling and administration of medication is in need of review and improvement. EVIDENCE: Key Standards 18 and 19 were assessed at the last inspection. Standard 18 was met in full, and a requirement made in relation to one resident’s healthcare needs has now been met. It was noted that night-time staff cover has been changed since the last inspection, to reflect concerns over the support needs of one individual, and that funding is being sought to make the provision of waking night staff a permanent arrangement. Arrangements for the administration, storage and handling of medication were assessed. The Home uses the Boots Monitored Dose System for the management of residents’ medication. A number of concerns were identified. A packet of Paracetemol tablets (500mg) was stored in the medicines cupboard. None of the residents has this prescribed: one member of staff suggested that the tablets were there for staff use. An immediate requirement was made that this medication should be removed. It was not possible to track effectively the precise amount of medication that should be held in stock, as amounts received were not always shown on the Medication Administration Record (MAR). The senior member of staff on duty
Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 13 was unable to explain how stocks were audited, or show how many tablets should be held at any given time. This was discussed subsequently with the Manager, and suggestions made about how this could be done. An unopened tube of cream had been stored for over six weeks. The Inspector was advised that this medication was no longer in use, and it was noted that there was no corresponding entry on the MAR sheet. Creams should be returned or disposed of after 28 days. Protocols were in place for PRN (“as required”) medication, but some of these were undated, and it was not possible to tell when they had last been reviewed. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 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): 23 All members of the care team should receive appropriate training in the recognition and prevention of adult abuse, so as to enhance the level of protection for people living in the house. EVIDENCE: Key Standards 22 and 23 were both assessed at the time of the last inspection. The staff-training chart on the office wall indicates that 50 of the current care team have yet to receive training in the Protection of Vulnerable Adults From Abuse, and a requirement was made that this situation be rectified (see Standard 35 also). Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 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): EVIDENCE: Key Standards 24 and 30 were assessed and met in full at the time of the last inspection. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 16 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): 32, 34, 35, 36 An up to date training and development assessment is required to assess fully staff competence, qualifications and training needs. Recruitment policy and practice in general promotes and supports residents’ protection, but one or two areas are in need of attention. Formal staff supervision is improving, and should meet required standards in the near future. EVIDENCE: Concerns were expressed previously about a perceived over-dependency on the use of agency personnel in the Home. The Manager advised that vacant posts have now been filled, and that agency staff are currently only being used to cover leave and sickness, where absolutely necessary. A current staff training and development plan is required in order to assess fully the qualifications, skills and competencies of the care team. The Manager advised that one senior care staff is currently studying for NVQ level 3, and another to NVQ level 2, and that both are also doing training under the Learning Disability Awards Framework (LDAF). She further advised that it is hoped to get new staff on LDAF training in April 2006, when new training budgets are available. The required training plan must show, for each member of staff, all relevant training completed and qualifications gained to date. It
Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 17 should highlight any gaps (including refreshers) and indicate when outstanding training is scheduled, and who is to deliver it. It is known that this Organisation operates a rolling programme of training for its employees. Recruitment records were examined, and required documents were generally in place. However, it was noted that one person’s file did not contain any proof of identification. On another member of staff’s file it was noted that the completed application included significant gaps in her employment history, and that these were not explained. In this particular case, it is likely that this person was not resident in the UK during the time in question, but the application should make this clear. Where it does not, appropriate enquiries should be made and the outcome duly recorded. Recruitment is generally dealt with from a central location, but this area of practice needs “sharpening”. It was noted that staff meetings are being held regularly, in accordance with National Minimum Standards. Formal supervision is not yet up to the required standard, but clear efforts are being made to rectify this. If progress continues at the current rate, it is anticipated that this standard will be met in the near future. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 18 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): 37, 39, 42 The Manager is making progress in the general running of the Home. A report of Quality Assurance and Monitoring activity should be produced, indicating how residents’ views have been used to underpin service review and development. General practice promotes residents’ health, safety and welfare. EVIDENCE: The Manager has now been in post for over twelve months. She reported that she has almost completed training to NVQ level 4, and is hoping to commence working towards the Registered Manager’s Award in the near future. An application for registration has been submitted to CSCI since the last inspection visit. Now that the overall staffing position has improved, it is hoped that further progress can be made to develop the service for the benefit of the people living in the house. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 19 The Organisation is developing its Quality Assurance and Monitoring Systems, and a number of measures are already in place in this regard. Visits required under Regulation 26 (Care Homes Regulations 2001) have generally been carried out as necessary in the past, and the newly appointed Operations Manager is continuing this, as appropriate. The regulation requires that these visits should be unannounced, but correspondence on the office notice board suggests that this is not current practice. The Organisation should now collate information and report on the outcomes of its Quality Assurance and Monitoring activity, and make the findings available to interested parties. Safety records were sample checked. The fire alarm and emergency lighting systems have been tested regularly, and records kept as required. Fire evacuation drills have also been carried out. Records of testing of food and fridge / freezer temperatures were also complete. The Landlord’s Gas Safety Certificate was renewed in November 2005. It was noted that portable appliance testing of electrical equipment is due shortly, and also that the fiveyear electrical hard wiring certificate is now due for renewal. Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 20 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 X 2 2 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X 2 X 2 X X 3 X Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 YA2 Regulation 14(2) Requirement Summarise individual assessment information and use this to inform care plan development. Develop residents’ care plans as indicated in the main body of this report. Set goals with measurable outcomes and evaluate these at review as indicated. (Partially met) Develop risk assessments as indicated in the main body of this report. Cross reference each risk assessment to the care plan(s) to which it relates, and vice versa. (Partially met) Evaluate and review residents’ activities, so as to improve the range, quality and frequency of opportunities available to each individual. (Outstanding since 30/11/05) Ensure that all staff have received training in the Protection of Vulnerable Adults From Abuse. Forward to CSCI a current copy of the staff training and
DS0000016887.V281480.R01.S.doc Timescale for action 30/04/06 2. YA6 15(2) 30/04/06 3. YA9 13(4) 30/04/06 4. YA12 YA13 16(2m-n) 30/03/06 5. YA23 18(1a-c) 30/04/06 6. YA32 YA35 18(1a-c) 30/03/06 Copperbeech Version 5.1 Page 22 7. 8. YA36 YA39 18(2) 24(1-3) 9. YA42 13(4c) development assessment, as indicated in the main body of this report. Ensure that staff receive formal supervision at least six times in any twelve-month period. Produce a report of quality assurance and monitoring activity for the home, indicating how residents’ views have been taken into consideration. Forward a copy of the 5-year electrical hard wiring certificate to CSCI. 30/04/06 30/04/06 30/03/06 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 YA6 Good Practice Recommendations Further develop care plans to incorporate detailed communication guidelines for all residents, but in particular for the person who has an Autistic Spectrum Disorder. Seek professional help to develop communication skills of both staff and resident groups. Assess staff team’s understanding of how to risk assess appropriately, and seek further training if required. 2. YA9 Copperbeech DS0000016887.V281480.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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