Inspection on 09/10/07 for Copperbeech

This inspection was carried out on 9th October 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Copperbeech 09/11/06

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 Key Unannounced Inspection 9th October 2007 09:20 Copperbeech DS0000019964.V348297.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.V348297.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.V348297.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 F/P 01773 530937 None United Response Caroline Lee Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 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. Copperbeech DS0000019964.V348297.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 7.75 hours and was a key unannounced inspection. The Manager and SSWAR with Additional Responsibilities (SSWAR) were spoken to. 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. Records were inspected and there was a tour of the building. Two service users were 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 pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The Home’s fees were stated on Service Users’ Guides as ranging from £1158 to £1583 per week. A copy of the last inspection report, from the Commission for Social Care Inspection (CSCI), is available to service users and visitors in the office. What the service does well: What has improved since the last inspection? What they could do better: Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 6 Medicines should be more securely stored. The Manager should be provided with a course of Safeguarding Adults training by Derbyshire Social Services. Chairs and settees in the lounge should be replaced or repaired. More priority should be given to staff training at NVQ level 2 in care. 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.V348297.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.V348297.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. Each service user had an individual contract, set out in an appropriate format, to provide them with sufficient information about the service and its cost. 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. These statements were set out with photographs of staff and the Home and had ‘widget’ symbols. There was discussion with the Manager as to how alternative use of, for instance, ‘Picture Bank’ pictures might make the contracts more understandable to service users. The service users were unable to sign these contracts and two of them had no close relatives who could sign as representatives. The Manager said she plans to ask the third service user’s parents to sign. Copies of the contracts were being kept with a copy of the Service Users’ Guide. Copperbeech DS0000019964.V348297.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 good. This judgement has been made using available evidence including a visit to this service. Service users had individual and up to date plans of care which demonstrated that their health, personal and social care need were being met. A ‘person centred’ approach was being taken to ensure that service users’ individual needs and wishes were focussed on. EVIDENCE: The care plan of one case tracked service user was examined – others were not available on the day of this inspection as the hand written copies were being typed elsewhere. It was noted that the quality of the care plan documents had improved since the previous inspection. The care plan took a ‘person centred approach’ and listed a range of holistic topics that were personally important to the service user as well as matters that were important for the individual – these being action points for staff. Each group of topics had associated goals so forming a constructive and comprehensive care plan. The Manager explained that this service user’s care plan had been reviewed in September 2007 at the Home’s first ‘person centred’ review meeting. This had been attended by a good range of people relevant to the service user, Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 10 including that person, their relative, Home staff and day service staff. However, Derbyshire Social Services had not sent a care manager to this review meeting or any within the past two years, the Manager stated. She explained that full care plan review meetings were held annually and there were in-house reviews at alternative six-monthly periods. She added that ‘Monthly Summary Sheets’ were planned as a support to the six-monthly review process. Within service users’ files were also ‘Communication Charts’ that provided further insight into service users’ behaviour and needs so that the Home could approach these positively and constructively. All care plan documents seen had been dated though some were unsigned. They were all kept in a lockable cabinet, so addressing the confidentiality issue noted at the previous inspection. The SSWAR gave examples of service users making choices and taking decisions. He said that one of the case tracked service users will make it clear when they wish not to follow the day’s programme. This same service user will open a kitchen cupboard and choose items to eat for lunch. It was noted from the Home’s menu that ‘service users’ individual choices’ are recorded on certain days. The Home had rationalised and reduced the number of individual recorded risk assessments, since the previous inspection, so each service user had just one. Each covered a good range of topics and ‘Actions to be taken’ were well worded. However, it was not always clear what ‘Actions’ related to what ‘Risks’. The SSWAR gave examples of service users taking ‘responsible risks’ – that is, risks that increased their independence. For instance, one case tracked service user is aware of the risks associated with hot water and will make coffee in the kitchen. Copperbeech DS0000019964.V348297.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. The Home provided activities and services that were age-appropriate and valued by service users and promoted their 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. The third service user had a five-day week day service that was based at the Home. Discussion with the SSWAR indicated that service users were being provided with valued and fulfilling activities at the Home and at external day services. One of the case tracked service users had recently brought home something made for Halloween at day services. The other case tracked service user was said to be “eager” when baking a cake in the Home. Each of the service users had been provided with a seven night holiday this year. The Manager described how one case tracked service user had indicated a wish to go to Australia and look out of the plane Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 12 window. This comment reflected the Home’s person centred approach, in that service users were encouraged to voice their dreams and wishes and these were listened to. Service users had contact with a range of local community facilities. Staff had previously said that there were good links with the local community: service users and staff walk to the local convenience store and a number of local pubs are used too. One case tracked service user prefers one particular pub that has a quiet atmosphere. This was evidence of individual needs being catered for. The Manager spoke of plans for all service users to access a range of community resources, particularly in the context of the closure of United Response’s day services and resources released from this closure. One service user had regular family contact – both at the Home and at the family’s home. Another service user’s family now feel able to have the person visit their home every few weeks, the Manager reported, and they are visiting the Home more frequently. This is significant progress from the time of the previous inspection. The third service user had limited contact with relatives. The Manager spoke of an external advocate having been involved with this service user and of Derbyshire Advocates considering an involvement in this person’s care plan review meetings. General housekeeping tasks were recorded in each service user’s plan of care. The expectation of this was recorded in the Service Users’ Guide to the Home. The SSWAR agreed that daily routines promote independence for service users and gave, as an example, one service user’s routine of taking used clothes to the laundry and loading them into the washing machine. Staff then prompt to add soap. The Manager added that this service user had significantly developed in self-confidence and independence and in being more “comfortable” in the Home. Staff respect service users’ wishes to spend time on their own and the SSWAR stated that they are all able to indicate this wish. One service user was said to have a “private soak time” in the bath, with staff “hovering” outside on the landing in order to minimise risks. The Manager said that service users were involved, with staff, in planting, maintaining and picking vegetables from the rear garden, ready for cooking. All three service users enjoy gardening, she said. Food stocks were at a good level in the kitchen, and included fresh fruit and vegetables. A separate small refrigerator was available for one case tracked service user who chooses to sample the contents of the main refrigerator. This was another example of a person centred approach. The five-week rolling menu included theme-based evening meals, including Caribbean meals that reflected one service user’s ethnic background. Meals out for individuals were also included. The Manager said that frequent use was being made of ethnic food retailers and added that all service users were involved in food shopping and, to varying degrees, in food preparation. The menu indicated that service users were being provided Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 13 with a balanced and nutritious diet. Care plans made reference to service users’ food preferences. Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home was providing service users with personal support in the way they preferred and required and was meeting their health needs. EVIDENCE: Lists of service users’ ‘Likes and Dislikes’ were on file. The Manager said that one service user was attending a specialist barber who knew how to cut AfroCaribbean hair. She felt that service users’ styles of communication was central to understanding needs and pointed out that each service user’s ‘Communications Chart’ was a means of recording their behaviour as communication and this fitted in with the Home’s person centered approach. The Manager spoke of one service user understanding Makaton sign language and symbols as well as having some verbal ability. She said that one of the case tracked service users makes staff aware of needs by taking their hand and leading them to an object. The Inspector had observed this at the previous inspection. Overall, there was evidence of staff supporting service users to maximise control over their lives. Within the care planning documentation there was evidence of service users’ health needs being met. Service users had recently been provided with a ‘My Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 15 Health File’ each. These were appropriately person centred documents that give an overview of health related matters. They had replaced previous documents that had not been kept up to date. The Manager said that staff still 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 appointments. This was raised at the previous inspection and was a matter that was just about to be addressed, the Manager said. A ‘Health Appointments Record’ sheet was being introduced to provide an ‘at a glance’ record of health appointments to ensure none were missed. There was recorded evidence of appropriate involvement of health professionals. This included the involvement of a speech and language therapist with one case tracked service user at day services, using ‘intensive interaction’ – a means of relating to people who have very limited speech and comprehension abilities. The Manager said that staff at the Home also undertake ‘intensive interaction’ with service users. Service users’ Medication Administration Record (MAR) sheets were examined and found to be satisfactory. United Response’s written Medicines Policy still did not refer to the need to countersign and date hand written entries on MAR sheets. Service users’ prescribed medication was being kept in a large metal cabinet. It was not secured to the wall although it was heavy and the room it was in was kept locked. The instructions for the administration of ‘prn’ (as and when required) medicines were clearly documented, signed and dated and a well-worded protocol was in place regarding one case tracked service user’s ‘prn’ diazepam. No controlled drugs were being used. Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and abuse were in place, ensuring that service users were fully protected. 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 spoke of plans to improve this written procedure through the use of ‘Picture Bank’ pictures. She reported there had been no complaints about the service within the previous 12 months and 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 had attended a training course in ‘Safeguarding Adults’. She said she undertook this training in 2005 but had not attended training by Derbyshire Social Services on this subject. The SSWAR showed good awareness of the Home’s ‘whistle blowing’ policy. Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 17 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. Service users were living in a safe, comfortable and hygienic environment. EVIDENCE: The majority of carpets in the Home had been replaced since the previous inspection. Chairs and settees in the lounge were worn and some had no cushion covers. The Manager explained that funding had been approved for the replacement of these items of furniture although a delay had been experienced. Two service users had been fully involved in the choice of this furniture, the Manager said. There was a more homely feel in the dining room than in the lounge and kitchen areas and there was discussion with the Manager as to how this could be addressed. She stated that every bedroom was to be refurbished and each service user had chosen new furniture. All bedrooms were appropriately personalised and had lockable cabinets. There were attractive front and back garden areas. The Home was clean and free from odours. There were hand drying facilities and soap in the bathroom and toilets. The washing machine had a sluicing Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 18 cycle and the SSWAR 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 and said they had improved their self-help skills and reduced their challenging behaviour. Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 19 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): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home had a group of well-recruited and trained staff to ensure that service users were safe and their needs were met. EVIDENCE: None of the five permanent 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 was half way through completing his qualification at NVQ level 3 and one other member of care staff was within weeks of completing level 2. Following a requirement made at the previous inspection, a risk assessment had been recorded to address the potential risks associated with just one member of staff being on duty between the hours of 7am and 9am. This was satisfactory. Other aspects of Standard 33 were not assessed on this occasion. Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 20 The file of a member of care staff appointed in January 2007 was examined. The job advertisement was worded in a person centred way and the Manager described how service users had been involved in the recruitment process. All of the elements required by current Regulations, regarding recruitment practices, were in place. The Manager stated that notes had been made of reasons for gaps in this employee’s work history, at the interview, but there was no recorded evidence held in the Home. There was evidence of this same member of staff being provided with induction training to Skills for Care Common Induction Standards, as recommended by Standard 35. This induction was undertaken within three months of coming into post – an improvement from the position found at the previous inspection. Training records showed that all staff had been provided with all mandatory training. It was noted that the Manager had had only one session of supervision, and one annual appraisal, this year. There were no notes held in the Home of either of these sessions. Other aspects of Standard 36 were not assessed on this occasion. Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 21 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): 37,38,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home was well managed so that service users were protected and their best interests were promoted by the systems in place. EVIDENCE: The Manager had achieved her National Vocational Qualification (NVQ) in Care at level 4 and the Registered Manager Award. She had worked with people with learning disabilities for 7.5 years and had been in this post since July 2006. She said her post was additional to the staffing establishment. Her hours are split over the two homes she manages. The Manager stated in the pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire that “staff morale has risen considerably”. The SSWAR felt there had been significant improvements in the service users’ behaviour and, generally, in the Home since the present manager had been in Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 22 post. He said she had made “a very positive contribution to the Home” and her “good leadership results in sensitive working of the team”. He also remarked that “she has a vision” and this was confirmed by her completion of a comprehensive and thoughtful AQAA. Monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, were taking place. The Home’s annual ‘Action Plan’ was being used as a regular quality assurance tool. Quality assurance questionnaires had been sent to the parents of one service user, with whom there is good contact, and to the three care managers involved with the Home. The Manager said that a basic satisfaction questionnaire, for service users’ use, was being devised, based on “a simple visual template”. An existing advocate had agreed, in principle, to enable service users to complete these questionnaires. The Manager said that an Open Day was held in the summer at United Response day services to which relatives and external professionals had been invited. 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. Written risk assessments for the Home’s environment were examined and these were reviewed quarterly through a Health & Safety audit undertaken by the manager of another United Response home. The completed AQAA questionnaire indicated that equipment in the Home was being maintained and good Health and Safety practices followed. Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 23 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 3 X X 3 X Copperbeech DS0000019964.V348297.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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. 3. 4. 5. 6. 7. 8. Refer to Standard YA9 YA20 YA20 YA22 YA23 YA24 YA32 YA34 Good Practice Recommendations Recorded risk assessments should clearly identify what ‘Actions’ relate to what ‘Risks’. United Response’s written Medicines Policy should follow the guidance from The Royal Pharmaceutical Society. (This was a previous recommendation) Medicines should be kept within a cabinet that is secured to a wall. (This was a previous recommendation) There should be a more robust system for logging service users’ concerns. (This was a previous recommendation) The Manager should be provided with a course of Safeguarding Adults training by Derbyshire Social Services. (This was a previous recommendation) Chairs and settees in the lounge should be replaced or repaired. At least 50 of the care staff should achieve an NVQ in care at level 2. (This was a previous recommendation) A satisfactory written explanation of any gaps in employment, in respect of a job applicant, should be DS0000019964.V348297.R01.S.doc Version 5.2 Page 25 Copperbeech 9. YA36 retained in the Home. The Manager should be provided with regular, recorded supervision meetings at least six times a year. Copperbeech DS0000019964.V348297.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.V348297.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. 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