Inspection on 08/08/08 for Copperbeech

This inspection was carried out on 8th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copperbeech 21/09/07

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 13/11/2008.

CARE HOME ADULTS 18-65 Copperbeech 23 Copperbeech Drive Balsall Heath Birmingham West Midlands B12 8SN Lead Inspector Lesley Webb Key Unannounced Inspection 8th August 2008 03:30 Copperbeech DS0000016887.V369214.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.V369214.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.V369214.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) www.milburycare.com Milbury Care Services Ltd Miss Kim Jacqueline Powell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Copperbeech DS0000016887.V369214.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. 21st September 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 our visit the service user guide states the fee level for living at the home as £989.79 per week. Additional charges apply for some transport, meals and activities. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We carried out this inspection over one day, from 3.30pm to 8.30pm. The home did not know we were coming. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is 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 need further development. Prior to the inspection the home supplied information to us in the form of its Annual Quality Assurance Assessment (AQAA). Information from this was also used when forming judgements on the quality of service provided at the home. People who live in the home were case tracked. This involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Due to some residents communication needs they were not able to comment on the service they receive. Discussions with staff took place and we also gave feedback on our findings to the registered manager by telephone. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: Residents meeting take place that help people living at the home make decisions about the support they want. The choice and range of activities that people undertake appear to meet their needs. People living at the home receive varied and balanced meals. Staff treat residents with respect, talking to them as equals. The management of medication is good, offering safeguards to residents. Staff understand how to support residents if they are not happy. One person explained, “two of the residents can say if unhappy, others we have to look for signs, changes in mood, if asked one would nod head. I would tell the Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 6 manager, have a meeting to try to sort, call the area manager. Maybe refer to a specialist”. Staff are trained in adult protection so they know what to do to stop residents being harmed. Residents live in a safe, well-maintained and comfortable environment, which encourages independence. Staffing levels appeared adequate to meet people’s individual needs A number of checks are undertaken regularly by the home to make sure that the health and safety of people living there is maintained. What has improved since the last inspection? What they could do better: Residents must be supported to attend appointments as stated in their health care records. This will ensure their health needs are managed safely by the home. The home must ensure anyone, including agency workers have had the required checks as detailed in the Care Home Regulations. This will ensure residents are protected by the homes recruitment practices. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 7 An audit of residents’ files should be undertaken and any documents that are no longer needed removed and archived. This will help to ensure staff have access to accurate and up to date information needed to support residents. Residents and/or their representatives should be involved in the compilation and reviewing of their care plans so that the views of the resident are considered when planning care and support. Staff should receive further guidance with regard to person centred approaches to support to ensure they have enough knowledge to support residents. Work should be undertaken to ensure the home can evidence decision making on behalf of residents who lack capacity complies with the Mental Capacity Act. It would be good if activity plans could be put in a picture format so that they are easier for people who live in the home to understand. Action should be taken to ensure the two residents how have not been on holiday this year are given the financial equivalent in day trips. This will ensure no resident is dis-advantaged. Improvements to financial recording systems should be made to ensure residents’ rights are upheld and monies managed safely. It is strongly recommended that the recording systems and structures within the home are reviewed, with old documents archived, duplicated records removed and staff given further guidance with regard to the completion of records. This will help the home evidence that is provides a holistic and constant quality service to all residents. Please refer to the back of this report for a full list of recommendations. 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.V369214.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.V369214.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: As at the previous inspection a copy of the service user guide was available on each of the residents files we viewed. Since the last inspection this has been reviewed to include specific information with regard to fees charged for living at the home. Information within the service user guide states that services covered within the specified fees include maintenance, decoration and furnishings, staff, insurance, heating and lighting, rates, office overheads, pay for all food and drinks within the home, costs of specified activities out side of the home as agreed in contracts and £200 towards an annual holiday or day trips. Excluded from fees are personal toiletries, clothes, some furniture in bedrooms and electrical items in bedrooms such as a television. The service user guide also states ‘the additional cost of meals eaten outside of the home over and above the allowance made for meals within the home’ and ‘the cost certain activities outside the home not covered in contract’. Information about the allowance for each of these areas is not included in the service user guide. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 10 It is recommended that this information be included to ensure everyone is fully informed. 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. We did look at the homes admission policies and found that if these are adhered to prospective residents can be assured their needs will be identified before they move into the home. Since the last inspection assessments of needs have been reviewed for people already living at the home. These cover areas including physical, social, medical and psychological. None of the assessments contained evidence that the resident or their representatives have been involved in their compilation. This should take place so that the views of the resident are considered when planning care and support. If residents are not able to be involved in planning their care and have no family or representatives, advocates should be obtained. We noted that one persons assessment appears to contradict the contents of a care plan as it states that with regard to eat they are totally independent whilst their care plan and risk assessment gives instructions for support due to the risks from eating habits. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning processes have improved but there is little evidence of residents being supported in decision-making processes. EVIDENCE: All care plans that we looked at include long and short-term goals, give information how to attain these and dates when to be reviewed. Plans are in place for areas including health needs, personal care, communication and social support. In addition to the care plans each resident has a personal profile. This details areas including history, education, times of rising and likes and dislikes. As at the previous inspection because of the amount of information on peoples care files it was difficult to know what information is really important and it was also difficult to find particular information quickly. We spoke to the registered manager by telephone at the end of our visit advising that an audit of residents’ files be undertaken and any documents that are no longer needed removed and archived. This will help to ensure staff Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 12 have access to accurate and up to date information needed to support residents. It was pleasing to find that in-house reviews regularly take place, with evidence that relatives of residents being invited. We could find no evidence that multi-disciplinary reviews have taken place in the last twelve months for the two residents we case tracked. It is recommended that the home invite social workers to their in-house reviews and send copies of the minutes of these meetings to ensure everyone who has a legal responsibility to monitor the care packages people receive is fully informed. Staff that we spoke to gave good examples of the support needs of residents but confirmed that further guidance with regard to person centred approaches to support would be useful. As one person explained, “we should have done training on this but not been on it yet. Think it’s about respecting individuals rights”. As identified at the last visit one person has behaviours that challenge. All of these behaviours are now included in the care plan with guidelines available for staff to enable them to manage the behaviour safely, in a manner that respects the individual. Some care plans that we looked at state that residents do not have capacity to understand (for example health care and finances). Decision making care plans are in place that give basic information. They do not evidence a decision making protocol or the Mental Capacity Act being followed, make no reference to rights or the use of advocates. When giving feedback to the registered manager by telephone we explained that work should be undertaken to ensure home can evidence decision making on behalf of residents who lack capacity complies with the Mental Capacity Act. Staff that we spoke to demonstrated some understanding of the Mental Capacity Act and how this can affect the way they support people. For example one person explained, “it’s about the capacity of the client; don’t judge them, their rights”. We were informed that everyone has received training with regard to the Mental Capacity Act however it is recommended that staff receive further guidance about this to ensure they have sufficient knowledge to support residents. Also as at the previous inspection, it is acknowledged that some residents have communication needs that have the potential to impact on them being involved in decision making processes. However efforts must be made to overcome these to promote person centred approaches to care and support. There is some opportunity for people to select whether or not to take apart in an activity and where to spend time in the house. None of the care plans that we looked at contained evidence that the resident or their representatives have been involved in their compilation. This should take place so that the views of the resident are considered when planning care and support. If residents are not able to be involved in planning their care and have no family or representatives, advocates should be obtained. It is positive that regular residents meeting take place as an aid to involving residents in decision making. Further work should be undertaken to evidence requests made by residents in these meetings are acted upon. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 13 Risk assessments have been reviewed and now work in conjunction with care plans. We found that some care plans have a number of risk assessments (in some instances between 5 and 10) that work alongside the care plan. In some instances the contents of the risk assessments contained similar information. We discussed this with the registered manager by telephone advising that these be reviewed and combined into comprehensive risk assessments. Currently the number of supporting documents could mean important information is overlooked by staff due to the number of documents they have to read in order to know how to manage residents needs safely. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to engage in activities that meet their individual needs. EVIDENCE: The people who live at this home have a range of needs and are all very different. 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. By observing practices, talking to people and examining records we find that the choice and range of activities that people undertake appear to meet their needs. Activities that people participate in include meals out, walks in the local community, shopping and occasional trips to the cinema, bowling and swimming. Numerous records are maintained including activity plans, activity Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 15 logs and evaluation sheets. It appears that these cause some confusion for staff as not all activities recorded on plans are evidenced on the log sheets and the evaluation sheets do not give specific evaluations of activities but state if a resident has enjoyed activities for that week or not. In addition to this some activities are recorded in the individual residents diaries. The homes Annual Quality Assurance Assessment (AQAA) states a music therapist visits the home every 2 weeks and this can be evidenced in the visitor’s book and aromatherapy sessions take place every 2 weeks again evidenced in the visitors book. As with other activities we had difficulty tracking if this has been taking place as activity records and evaluation sheets do not evidence this on a regular basis. It is recommended that a review of the current recording systems is undertaken and a concise and accurate system implemented for recording and evaluating activities. Also it would be good if activity plans could be put in a picture format so that they are easier for people who live in the home to understand. A resident that we spoke to confirmed (with assistance from staff) their enjoyment of a recent holiday to Devon. Staff informed us that two of the four residents have been on holiday this year and the others have not as they do not like holidays. The service user guide states that the home will pay £200 towards the cost of an annual holiday or the equivalent in day trips. We could not find evidence that the two residents who have not been on holiday having been on daytrips. Action should be taken to ensure this takes place so that no resident is dis-advantaged. As at previous inspections family contacts is variable. One person has twiceyearly 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 living at the home receive varied and balanced meals. As at previous inspections menus are completed weekly and individual records of meals taken maintained. Those sampled were varied and culturally appropriate. There were adequate supplies of food in the home including fresh fruit and snacks and drinks. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. People are supported to meet their personal care needs. In the main people’s healthcare needs are met. Improvements to the monitoring of wellbeing will promote a holistic approach to health care management. EVIDENCE: All of the previous requirements and recommendation with regard to personal and health care support are now met. These include the implementation of risk assessments for support needed by night staff, referrals to health specialists and the completion of health action plans. All of these improvements help ensure the health needs of residents are met. During our visit we noted that all residents been supported to dress appropriately to their age and gender. We observed that staff treated residents with respect, talking to them as equals. Staff were heard to remind residents to wash their hands after using the bathroom, promoting good hygiene. As mentioned earlier in this report care plans now include personal preferences such as times of rising, routines with personal care and assistance Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 17 with bathing. This means personal and health care is given in a person centred way. Records show that peoples weight is monitored on a regular basis and that they attend a variety of health care specialists dependant on their individual needs. One residents health records state they attended a hearing appointment March 2007 with records stating ‘waiting letter for referral’. We could not find evidence of this being followed up. Another resident’s health records state they attended a chiropody appointment March 2007 and that a follow up appointment is needed in 3 months. Again we could not find evidence of this. The same person attended a health check January 2007. These are usually recommended to take place annually. We could not find evidence of this. Also a residents care plan with regard to physical health states they must have a yearly flu inoculation. We could not find any evidence of this taking place. We discussed these issues with the registered manager by telephone when giving feedback on our visit. We explained that improvements to the monitoring of appointments should take place, as these currently do not demonstrate a holistic approach to health care monitoring. As at the previous inspection the management of medication is good, offering safeguards to residents. The home operates a monitored dosage system for medication administration. Medication is stored securely within a locked cupboard in the office. Medication administration records were sampled and found to be accurate. All records for medication entering, being administered and leaving the home were found to be in good order. Good protocols are in place for the use of PRN (as and when required) medication. These give good instructions to staff that ensure medication is administered safely. At the last inspection the home was advised to obtain residents consent to the administration of medication by staff. We found an information sheet on each of the residents’ files we looked at but no written consent. When giving feedback to the registered manager by telephone we advised that the information sheet by itself does not constitute consent and further work should be undertaken in this area. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaint procedures ensure concerns are acted upon. In the main people are protected from abuse and harm. Systems for the management of resident’s personal monies are not robust. This means their rights are not being upheld. Some recruitment practices do not ensure residents are safeguarded from harm. EVIDENCE: The organisation has a complaints procedure that is also available in an easy read format that includes some pictures. CSCI have not received any concerns, complaints or allegations since the last inspection about the home. No complaints have been received at the home in twelve months. It would be difficult for some people who live at the home to express their opinions or complain about the service received and are reliant on staff interpreting their wishes or behaviours for them. It was pleasing therefore, that all staff spoken to demonstrate an understanding of their responsiblities in this area. For example one person explained, “two of the residents can say if unhappy, others we have to look for signs, changes in mood, if asked one would nod head. I would tell the manager, have a meeting to try to sort, call the area manager. Maybe refer to a specialist”. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 19 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. The policy on abuse and whistle blowing policy was available in the office for staff to refer to. Staff that we spoke to demonstrated good understanding of protecting residents. For example one explained, “Would have to report, look at way other staff talk to residents, lots of different forms of abuse, drug, hitting, financial, sexual, emotional, look for bruises when bathing, question, check accident records, report to manager or higher”. As mentioned earlier in this report staff should receive further guidance on the Mental Capacity Act, as this Act provides a statutory framework to empower and protect vulnerable people who may not be able to make their own decisions. The home holds people’s personal money on their behalf. Both of the residents’ files we looked at contained finance care plans that state they are not able to manage their own finances, as they do not have understanding. As already mentioned in this report work should be undertaken to ensure decision making protocols are in place that demonstrate if a resident lacks capacity the Mental Capacity Act is complied with. Individual records are maintained for residents’ income and expenditure, along with receipts. A document at front of the finances file titled ‘contribution towards transport costs, external day activities and meals’ states ‘Milbury will contribute £38 per week per service user towards transport costs e.g. taxi. All additional costs will be incurred by the service user. Millbury will contribute £8 per week per service user towards external day activities. All additional costs will be incurred by the service users. Millbury’s contribution towards service users meals away from the home will remain the same’. We found a number of recordings sheets contained in this file for recording monies but some appeared to have been recorded on the wrong sheets (for example a sheet titled activities was found to have taxi fares recorded on it) and we could not track what had been contributed by the home and what had been paid for out of residents personal monies. Overall with regard to finances there appears to be a system in place where the home makes a contribution but this is not clear and easily auditable. It is recommended that improvements to recording systems are made to ensure residents’ rights are upheld and monies managed safely. We also noted that two residents have accrued high levels of personal savings that could affect state benefits they receive if they continue to increase. When feeding back by telephone to the registered manager we advised that the home should explore ways of spending money that would benefit residents in order that their state benefits are not affected. This should also include involving social workers and next of kin. Recruitment records sampled show that a robust procedure is not being followed at all times for the protection of people living in the home (detailed further in the staffing section of this report). Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: We looked around the home and found no health and safety concerns. The home is a small domestic style property comprising of four single bedrooms. The first floor is accessed via a stairway and people have to be mobile to access rooms on the first floor. 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 a small office. We noted that some carpets in communal areas are stained and would benefit from cleaning. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 21 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. As at the previous inspection satisfactory infection control procedures were in place. The home was clean and free from unpleasant odour. Information supplied to us in the homes Annual Quality Assurance Assessment (AQAA) states that four staff have received infection control training. It is recommended greater numbers of staff undertake this to further promote good infection control. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff generally have the skills and knowledge to support residents. Gaps in recruitment records mean residents cannot be assured they are supported by staff who have had the required checks to ensure they are safe. EVIDENCE: As at the previous inspection staff were observed interacting with people living in the home in a friendly and respectful manner. Two support workers were on duty, and staffing levels appeared adequate to meet people’s individual needs. The recruitment practices for permanent staff appear appropriate, offering protection to residents. Two staff files were examined; both contained a completed application form, references, criminal bureau checks and training details. We examined the staffing rotas for June, July and August 2008 and found that the home as been using agency staff to cover vacancies. The rotas were difficult to evaluate as they do not include the full names of agency workers and correction fluid has been used in many instances. We found timesheets for agency workers and these detail nine agency staff completing seventeen shifts between April and July 2008. We found a sheet that states Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 23 confirmation of Criminal Records Bureau (CRB) check, references and training having been obtained for five of the agency workers. We found no evidence that suitable checks have been undertaken for the remaining agency workers. When giving feedback to the registered manager by telephone we asked how she had verified the information for the five agency workers. She informed us the recruitment agency had verbally confirmed this information to her. She had not asked for written confirmation of this information. She also confirmed that no records or verification was in place for the other agency workers, stating this was something she had only recently started. We explained that it was the homes responsibility to ensure anyone, including agency workers has had the required checks as detailed in the Care Home Regulations. This ensures residents are protected by the homes recruitment practices. Since the last inspection the manager has completed 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. As mentioned earlier in this report work now needs to be undertaken to ensure care practices and documents reflect consideration of this new legislation where appropriate. We found it difficult to accurately assess if acceptable numbers of staff have received training in all areas to meet residents’ needs. Training information is maintained in several formats including a training file and two separate training matrix’s. We discussed this with the registered manager by telephone at the end of our visit who confirmed currently there is no one document that captures all training undertaken by everyone working at the home. It is recommended this is addressed to promote good monitoring systems. We were informed all staff have undertaken autism and Makaton training. This helps equip them with the knowledge to support people living at the home. There are currently eight permanent staff employed at the home. We were informed two hold a National Vocational Qualification at level 2 and that one of these also holds this at level3. Work should be undertaken to ensure greater numbers of staff undertake this qualification to ensure they are suitably qualified to support people living at the home. Since the last inspection staff meetings have been re-instated. These give staff the opportunity to discuss service provision and are a good support mechanism. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some management responsiblities need to improve to ensure residents’ benefit from a well run home. Quality monitoring systems continue to be developed so that people living at the home can be assured their views are taken into consideration. In the main the health and safety of residents is promoted and protected. EVIDENCE: The registered manager was approved by CSCI in August 2006. She has completed the required NVQ4 training and is in the process of completing the Registered Managers Award. She was not present during our inspection but we spoke to her on the telephone at the beginning and end of our visit to clarify some areas and to give feedback on our findings. Progress has been Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 25 made on previous requirements however there are a number of further issues that do require follow up as detailed in the care planning, protection and staffing sections of this report. These need to be acted upon to ensure residents receive a good quality service and that they are protected from harm. As mentioned in many sections of this report we had difficulty assessing some elements of service provision due to some recording practices. Some of the people who live at this home have communication needs that impact on them saying if they receive the care and support in they way they need and want. This makes the home more reliant on good recording systems to evidence this. It is strongly recommended that the recording systems and structures within the home are reviewed, with old documents archived, duplicated records removed and staff given further guidance with regard to the completion of records. This will help the home evidence that is provides a holistic and constant quality service to all residents. Quality monitoring systems include an annual service review to see if people at the home are getting a good service, this covers areas such as food, daily living and the premises. A development plan is available following the review. Prior to this inspection the home sent us its Annual Quality Assurance Assessment (AQAA) as we requested. The contents of this were brief in parts and give minimal information about the service provided to residents. It is recommended that greater detail is included when next requested by the CSCI. This will evidence further quality services that residents receive. The Operations Manager visits the home and writes a report of their visit as required under Regulation 26. Reports available in the home showed these visits are generally done monthly. Since the last inspection all the requirements and recommendations made with regard to fire management have been met, offering further safeguards to residents. For example the fire procedure has been updated and a new fire risk assessment implemented. A number of checks are undertaken regularly by the home to make sure that the health and safety of people living there is maintained. Systems are in place to monitor emergency lighting and 3 monthly fire drills take place. We were informed that all permanent staff working at the home have received training in first aid, food hygiene, health and safety and fire. This means people living at the home are supported by knowledgeable staff. Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 2 X 3 X Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 12(1) Requirement Timescale for action 01/09/08 2 YA34 19 Residents must be supported to attend appointments as stated in their health care records. This will ensure their health needs are managed safely by the home. The home must ensure anyone, 01/09/08 including agency workers has had the required checks as detailed in the Care Home Regulations. This will ensure residents are protected by the homes recruitment practices. 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 YA2 Good Practice Recommendations That information about contribution costs for transport, activities and meals is included in the service user guide so that everyone is fully informed. Residents and/or their representatives should be involved in the reviewing of assessments of needs so that the views of the resident are considered when planning care and support. DS0000016887.V369214.R01.S.doc Version 5.2 Page 28 Copperbeech 3 YA6 An audit of residents’ files should be undertaken and any documents that are no longer needed removed and archived. This will help to ensure staff have access to accurate and up to date information needed to support residents. Residents and/or their representatives should be involved in the compilation and reviewing of their care plans so that the views of the resident are considered when planning care and support. The home should invite social workers to their in-house reviews and send copies of the minutes of these meetings to ensure everyone who has a legal responsibility to monitor the care packages people receive is fully informed. Staff should receive further guidance with regard to person centred approaches to support to ensure they have enough knowledge to support residents. Work should be undertaken to ensure home can evidence decision making on behalf of residents who lack capacity complies with the Mental Capacity Act. Staff should receive further guidance about the Mental Capacity Act to ensure they have sufficient knowledge to support residents. Efforts should be made to support people with communication needs to be involved in decision making processes. This will promote person centred approaches to care and support. Work should be undertaken to evidence requests made by residents in these meetings are acted upon. Risk assessments should be reviewed and combined into comprehensive documents. This will help staff have ready access to important information. A review of the current recording systems for activities should be undertaken and a concise and accurate system implemented for recording and evaluating activities. It would be good if activity plans could be put in a picture format so that they are easier for people who live in the home to understand. Action should be taken to ensure the two residents how have not been on holiday this year are given the financial equivalent in day trips. This will ensure no resident is disadvantaged. 4 YA7 5 YA8 6 7 YA9 YA14 Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 29 8 9 YA20 YA23 People’s consent to receive medication should be sought and recorded in their care plan. Improvements to financial recording systems should be made to ensure residents’ rights are upheld and monies managed safely. The home should explore ways of spending money that would benefit residents in order that their state benefits are not affected. This should also include involving social workers and next of kin. Correction fluid should not be used on staff rotas and the full names of anyone who undertakes a shift at the home should be recorded on the rota. Service user meetings should be developed so that there is evidence that issues raised by people in the home have been followed through. Greater detail should be included in the AQAA when next requested by the CSCI. This will evidence further quality services that residents receive. It is strongly recommended that the recording systems and structures within the home are reviewed, with old documents archived, duplicated records removed and staff given further guidance with regard to the completion of records. This will help the home evidence that is provides a holistic and constant quality service to all residents. 10 11 YA33 YA39 12 YA41 Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Copperbeech DS0000016887.V369214.R01.S.doc Version 5.2 Page 31 - 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. 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