Inspection on 09/11/06 for Copperbeech

This inspection was carried out on 9th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Copperbeech 09/10/07

Copperbeech 27/01/06

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 Tony Barker Unannounced Inspection 9th November 2006 09:30 Copperbeech DS0000019964.V319647.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 DS0000019964.V319647.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 DS0000019964.V319647.R01.S.doc Version 5.2 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 www.unitedresponse.org.uk United Response Caroline Lee Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 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. The fees currently average £1207 per week. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8 hours and was a key unannounced inspection. The service users had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. The Manager and one support worker were spoken to and records were inspected. There was also a tour of the premises. One service user was case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The preinspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? What they could do better: There is need to improve the quality of the care planning system to ensure that documents are up to date and reflect service users’ current lifestyles and preferences. The potential risk to service users of the unprotected garden pond must be addressed. Staffing levels must be reviewed to ensure service users’ and staff safety. There must be a return to regular monthly independent service audit visits and improvements must be made to the Home’s quality assurance system to ensure that views of service users and Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 6 other stakeholders are taken account of. Further improvements should be made to the Home’s medicine policy and storage system and to the quality of carpets. The need for staff to achieve a National Vocational Qualification should be prioritised. 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 DS0000019964.V319647.R01.S.doc Version 5.2 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 DS0000019964.V319647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had their needs assessed before admission to the Home so that staff could provide individually tailored care. Their individual contracts with United Response were not complete. EVIDENCE: The three service users had lived in this Home for several years. A full assessment of both service users’ needs was made prior to their admission, as confirmed by detailed examination of care records at a previous inspection. Examination of documents confirmed that staff had based their care plans on these assessments. The Home provided a complete statement of terms and conditions/contract for each service user, included in the service users’ guide. These statements had been individualised to the Home except that staff photographs were still not in place. The Manager was unsure whether these individual statements of terms and conditions of residence had been signed on behalf of servicer users and given to them with the service users’ guide. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were not always benefiting from the care planning system as it did not reflect their changing needs. They were making decisions about their lives, with assistance, and were being supported to take risks to improve their independence. EVIDENCE: Support Plans, Behaviour Management Plans and risk assessments were comprehensive and were helpfully guiding staff in their work with service users. The Support Plans were based on the service users’ skills and did not reflect their broad ranging needs nor have any goals recorded. They had not been signed or dated and there was no evidence, on the tracked service user’s file, of them being reviewed and up-dated. The support worker who was spoken to felt that these care planning documents did not always give clear or up to date accounts of service users’ behaviour. She had worked for six months at the Home and gave an example of one service user exhibiting challenging behaviour during a recent trip to a local fair. She had not been informed of the potential for this behaviour. A review of all care planning documents, with a view to editing any unneeded or repetitive documentation, Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 10 had been started but not completed, the Manager explained. It was noted that the index to the case tracked service user’s file did not always reflect items’ position in the file. The care plan documents did not include statements about elements of the National Minimum Standards that had not been carried out due to unsuitability or service user incapacity. From discussion with the Manager about deficiencies within the Home’s records it became clear that staff would benefit from training in the use of records. The Manager produced a document called a ‘Listen to me Workbook’. It is proposed that this will become a person-centered care plan with goals that are chosen by each service user. This approach will also encourage staff to work pro-actively with service users. Other documents relating to service users, such as daily logs and medicine sheets, were filed in the daily records file. This was being kept in the kitchen, in an open box that could easily be read by anyone in the room. Concerns over confidentaility were shared with the Manager. The support worker who was spoken to gave examples of service users making choices and taking decisions. She said that the case tracked service user will open a kitchen cupboard and choose items to eat for lunch. The previous week another service user had told staff he did not want to go out for a drive and, instead, he opted to stay in and watch a television programme. It was noted, during this inspection, that the case tracked service user was more relaxed than at a previous inspection and had positive interaction with staff on duty. There was an extensive range of risk assessments recorded with regard to each service user. Individual risk assessments included a section entitled ‘What are the benefits from taking the risks?’. This showed that staff were being encouraged to enable service users to take ‘responsible risks’ – that is, risks that increased their independence. The Manager spoke of plans to rationalise and reduce the number of risk assessments. Those on the casetracked service user’s file had mainly only dates recorded to indicate a review – very few had associated comments. The Manager spoke of plans to address this. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were involved in fulfilling and age-appropriate activities within the Home and in the local community. They were able to maintain appropriate family relationships, where available, and were provided with a healthy personalised diet. Daily routines reflected their individual choice and promoted independence. EVIDENCE: Each service user had a weekly programme of activities. One service user was attending a Social Services Day Centre four days a week with a ‘personal day’, spent with the Home’s staff, one day a week. A second service user was attending United Response day services although, on the day of this inspection, he was on a five-day holiday with two support staff from the Home. The third, case-tracked, service user had a five-day week day service that was based at the Home. Previous discussions with support staff had indicated that service users were being provided with valued and fulfilling activities at external day services. The Manager described, at this inspection, a range of new opportunities, within the Home, that had been provided for service users. She said that two service users had, the previous evening, made a treacle Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 12 sponge with her. They were very proud of their achievement – as evidenced by a large smile on their faces, she said. These activities were increasingly reflecting individual needs and the previous inertia within the Home was now being challenged, she added. The support worker who was spoken to said that there were plans for one service user to become a member of a local rambling club and for two to use a local swimming pool. Also, craft materials had been ordered for service users to make Christmas cards at the Home. Service users had contact with a range of local community facilities. The support worker said that service users and staff walk to the local convenience store and a number of local pubs are used too. She added that the case tracked service user prefers one particular pub that has a quiet atmosphere. This was evidence of individual needs being catered for. One service user had regular family contact – both at the Home and at the family’s home. The other two service users had minimal or no contact. The Manager spoke of an external advocate having been involved with these two service users and of plans for this relationship to be extended to include involvement in care review meetings. General housekeeping tasks were recorded in each service user’s plan of care the expectation of this was being recorded in the Service Users’ Guide to the Home. The support worker who was spoken to said that service users could choose not to partake in any of the activities within or outside of the Home. Her opinion was that daily routines promoted independence for service users. She gave, as an example, the case tracked service user stripping the bed each morning, without prompting, and putting the linen in a laundry basket and then taking down to the laundry room, leaving it outside the locked door. The service user later loads the washing machine and switches it on. The Manager said that service users were involved, with staff, in planting, maintaining and picking vegetables from the rear garden, ready for cooking. She said that the case tracked service user has enjoyed picking beans and planting and watering tomatoes in the greenhouse. All three service users enjoy gardening, she said. Food stocks were at a good level in the kitchen, and included fresh fruit and vegetables. The Manager had introduced themebased evening meals and gave, as an example, Caribbean meals being part of a new five-week rolling menu. This reflected the ethnic background of one service user. She added that frequent use was being made of ethnic food retailers and said that all service users were involved in food shopping and, to varying degrees, in food preparation. A new menu sheet was examined and indicated that service users were being provided with a balanced and nutritious diet. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were not always receiving personal support in the way they preferred. Their health needs were being met and they were generally being protected by the Home’s procedures for dealing with medicines. EVIDENCE: A list of one service user’s ‘Likes and Dislikes’ was on file and examined. It included what food the service user liked and stated, ”Likes all food and doesn’t appear to have any dislikes”. The Manager was recommended to consider whether this service user had any actual food preferences. The Manager noted that this list had not been reviewed for at least 18 months as a number of this service user’s likes and dislikes did not reflect current lifestyle. This document was therefore not being actively used by staff. There was no similar list on the case tracked service user’s file. The Manager said that one service user was attending a specialist barber who knew how to cut AfroCaribbean hair. The Manager felt that service users’ styles of communication was central to understanding needs. She produced a ‘Communications Chart’ which she was aiming to use instead of the Home’s ‘Behaviour Management Plans’. This was a useful means of recording service users’ behaviour as communication and would form part of the Home’s person-centered care plans – as mentioned in Standard 6 of this report. The Manager spoke of one service Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 14 user understanding Makaton sign language and symbols as well as having some verbal ability. She said that there were plans to produce a ‘Life Book’ for this service user, jointly with day services, and a calendar with photos and pictures to help the service user to keep track of future events and aid communication with staff. The Manager said that the case tracked service user makes staff aware of needs by taking their hand and leading them to an object. The Inspector observed this service user bringing a CD into the room in order to communicate a wish to listen to music. Staff were then observed to encourage the service user to place the CD on the machine. A ‘Health Checks Record’ sheet, relating to the case tracked service user, was examined. It had not been kept up to date. The Manager said that staff complete a ‘Feedback Report’ whenever a visit is made to a health professional. These Reports were seen but could not, in themselves, provide a quick overview of health related matters. However, within the care planning documentation there was evidence of service users’ health needs being met. There was also recorded evidence of appropriate involvement of health professionals. The support worker spoken to confirmed this. Service users’ Medication Administration Record (MAR) sheets were examined and found to be satisfactory. There were no hand written entries – the Manager confirmed her awareness of the need to sign, countersign and date such entries. However, this practice was not fully supported by United Response’s written Medicines Policy. This made no mention of the need to countersign handwritten entries. Service users’ prescribed medication was being kept in a large metal cabinet. It was not secured to the wall although the room it was in was kept locked. The instructions for the administration of medicines required ‘as and when’ (prn) were clearly documented, signed and dated. The process by which changes to medication are recorded on MAR sheets had been reviewed so as to maintain a clear set of records. No controlled drugs were being used. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from the Home’s complaints policy and procedures although there could be a more robust system for recording their views and concerns. They were being protected from abuse. EVIDENCE: The Home’s written complaints procedure and complaints record form were examined and found to be satisfactory. A displayed version of the complaints procedure was in a mixture of words and Makaton sign language symbols. The Manager reported there had been no complaints about the service within the previous 12 months. She said that staff record, on daily logs, when service users appear happy or ‘off colour’. This was an ‘ad hoc’ process and not a robust system for logging service users’ concerns. These concerns may take the form of unhappiness, boredom, grumbles, withdrawal or aggressive behaviour. 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 and Derbyshire Report forms. The Manager reported that all staff, except the most recently appointed staff, had attended a United Response training course in ‘Safeguarding Adults’ (understanding and responding to adult abuse). She said she undertook this training in 2005 but had not attended training by Derbyshire Social Services on this subject. The support worker who was spoken to showed good awareness of the Home’s ‘whistle blowing’ policy. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users were living in a comfortable and homely environment that was clean and hygienic. The safety of service users was being potentially compromised through an unprotected garden pond. EVIDENCE: All rooms in the Home had been redecorated since the previous inspection. Repairs had been made to damaged plasterwork. However, there were still carpets in need of replacement. The Manager explained that funding approval was being sought for the majority of carpets to be replaced and for new settees in the lounge. There was a more homely feel than at the previous inspection and some areas were nicely personalised. In the rear garden there was a rabbit and guinea pig ‘run’ and a pond with goldfish. The Manager said that service users were involved in the maintenance of these pets as well as the compost heap and garden generally. There was no risk assessment to address the potential risk, to service users, of the unprotected pond. The Home was clean and free from odours. There were hand drying facilities and toilet tissue in the bathroom and toilets. There was still one WC seat that Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 17 did not stay upright, which could potentially cause problems for the three male service users and compromise hygiene. The washing machine had a sluicing cycle and the support worker who was spoken to provided evidence of good hygiene practice in relation to the transportation of infected materials, such as wet bedding, around the Home. The Manager reported how service users were being helped to develop hygiene skills – explaining that toilet rolls were now being left in toilets and toilet roll holders were being planned for the walls. This was a reflection of service users’ improved self-help skills and reduced challenging behaviour, she said. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were not being supported by a qualified staff group and they were being put at some potential risk by inadequate staffing during early mornings. Service users were protected by the Home’s recruitment procedures. EVIDENCE: None of the care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. The National Minimum Standard is to maintain a staff group with at least 50 qualified staff. The Manager stated, in response to this unsatisfactory situation, that the Senior Support Worker with Additional Responsibilities had almost completed his qualification at NVQ level 3 and two other care staff should have completed level 2 by the end of 2007. The Pre Inspection Questionnaire, completed by the Manager, showed that only one member of staff was on duty each morning between 7am & 11am and, at weekend evenings, from 7pm. The support worker who was spoken to said she felt that it was not totally safe, in the mornings, with only one staff on duty. The Manager pointed out that there was only one service user, in the Home, from 9am during week days but accepted that it could be difficult for staff between 7am and 9am. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 19 The file of a member of care staff appointed in May 2006 was examined. It was found to contain all of the elements, required by current Regulations, regarding recruitment practices. There was evidence of this same member of staff being provided with induction training to Learning Disability Award Framework (LDAF) standards, as recommended by Standard 35. However, this member of staff confirmed that this induction was undertaken belatedly and she had not received any valid induction training until the present manager came into post in July 2006. Training records showed that all staff had been provided with all mandatory training and the support worker spoken to confirmed she had received good levels of training since July 2006. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 20 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from a well run home and their health and safety was being promoted. They were not benefiting from an effective quality assurance system, where views of service users and other stakeholders were taken account of. EVIDENCE: The Manager had achieved her National Vocational Qualification (NVQ) in Care at level 4 and was anticipating completing the Registered Manager Award training course in March 2007. She had worked with people with learning disabilities for 6.5 years and had been in this post since July 2006. She said her post was now additional to the staffing establishment. Her hours are split over the two homes she manages. The support worker who was spoken to said that there had been a significant improvement in the management approach since the present manager had Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 21 been in post. This had positively affected service users’ behaviour, she added. She spoke enthusiastically about working with service users and “experiencing new things with them”. Other aspects of standard 38 were not assessed on this occasion. Monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, were not taking place. The Manager said that United Response was only planning an independent audit every year. The Home’s annual ‘Action Plan’ was examined. This was usefully holistic with objectives and some target dates – though there some objectives being evaluated within an ‘Ongoing’ timescale. No quality assurance questionnaires were in use, in order to assess opinions on the quality of service provided by the Home. However, the Manager said that draft questionnaires were being sent to service users and relatives. She added that an existing advocate had agreed, in principle, to enable service users to complete these questionnaires. No questionnaires were planned to be sent to staff or external professionals, who would have a view on the Home. The Manager said that an Open Day was planned for the United Response Derwent Area to which relatives and external professionals would be invited. This would improve ‘networking’ she said. Good food hygiene practices, and safe storage of cleaning materials, were observed. Weekly fire alarm tests were recorded as well as monthly fire drills – with night time fire drills being held every six months. The Manager said that there were written risk assessments for the Home’s environment. The pre-inspection questionnaire, completed by the Manager, indicated that equipment in the Home was being maintained and good Health and Safety practices followed. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 22 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 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 15(1) Requirement Service users’ care plans must be holistic - covering all aspects of personal, social and healthcare needs - with associated goals. (This was a previous requirement) Risk assessments, as well as other recorded service user plans, must be reviewed/updated and comments recorded. (This was a previous recommendation). All service users’ care planning documents must be working documents and reflect their current lifestyles. The potential risk to service users of the unprotected garden pond must be addressed through a recorded risk assessment and then efforts to minimise the risk. Staffing levels between 7am & 9am must be reviewed, with associated risk assessments being written to ensure service users’ and staff safety. Monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, must take DS0000019964.V319647.R01.S.doc Timescale for action 01/03/07 2. YA6 14(2) 15(2)(b) 01/02/07 3. YA6 YA18 14(2) 15(2)(b) 13(4)(c) 01/02/07 4. YA24 01/01/07 5. YA33 18(1)(a) 13(4)(c) 01/01/07 6. YA39 26 01/01/07 Copperbeech Version 5.2 Page 24 place. 7. YA39 24(1) 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. (This was a previous requirement) 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 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 service users’ guide. (This was a previous recommendation) All records in use at the Home should be signed and dated. Care plans should include statements about elements of the National Minimum Standards that have not been carried out due to unsuitability or service user incapacity.(This was a previous recommendation) The registered person should complete a review of care planning documentation and edit any unneeded or repetitive documentation. (This was a previous recommendation) Staff should be provided with training in ‘the use of records’. The daily records file should be kept within a cupboard to ensure a reasonable amount of confidentiality is maintained. ‘Likes and Dislikes’ lists should reflect actual preferences, be kept up to date and be in place for each service user. The manner in which service users’ Health appointments are recorded should be reviewed and kept up to date. United Response’s written Medicines Policy should follow the guidance from The Royal Pharmaceutical Society. Medicines should be kept within a cabinet that is secured to a wall. There should be a more robust system for logging service DS0000019964.V319647.R01.S.doc Version 5.2 Page 25 2. 3. YA6 YA6 4. YA6 5. 6. 7. 8. 9. 10. 11. YA6 YA6 YA18 YA19 YA20 YA20 YA22 Copperbeech 12. 13. 14. 15. 16. 17. YA23 YA24 YA24 YA30 YA32 YA39 users’ concerns. The Manager should be provided with a course of Safeguarding Adults training by Derbyshire Social Services. The registered person should replace the carpet in the main lounge. (This was a previous requirement) The bedroom carpet, identified in the previous inspection report, must be cleaned or replaced. (This was a previous requirement) The problem of WC seats not staying upright should be addressed.(This was a previous recommendation) At least 50 of the care staff should achieve an NVQ in care at level 2. (This was a previous requirement) The Home’s ‘Action Plan’ should have a target date for each objective. Copperbeech DS0000019964.V319647.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 DS0000019964.V319647.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!