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Inspection on 19/10/06 for Coppice Lodge

Also see our care home review for Coppice Lodge for more information

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Information is available about the services offered at the home to help people choose whether or not to live at Coppice Lodge and if the home will meet their needs. Service users are helped and supported to lead active and interesting lives at Coppice Lodge. They are also supported to stay in touch with their families and to develop friendships. The home offers a well-balanced diet and promotes healthy eating for the welfare of all service users. Personal and healthcare needs are written in care plans and provide information to make sure that care is provided in a way that service users like. The home has a medication policy and procedure to make sure that all medication is given and stored safely for the protection of service users and staff. The home`s complaints procedure has easy to understand information about how to complain. Staff support service users to have their say and to share any concerns they may have. Coppice Lodge is a safe, spacious and very comfortable home. The home is kept clean, tidy and well decorated. There are enough staff at the home, and the staff are trained to help them support service users. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home makes sure that suitable staff are employed and that all necessary checks are made to keep service users safe. The home is well managed with an open and positive approach.

What has improved since the last inspection?

Handwritten medication records are now signed by two people to make sure the records are correct. Daily records are now kept to monitor the effect of medication and any action that is taken to respond to this. Unused medication is now returned to the pharmacy. A system has been introduced to make sure that the quality of service provided by the home is monitored. All staff are trained in first aid. All staff have fire training every three months. Fire safety checks are now completed regularly.

What the care home could do better:

The home is well managed, well maintained and provides a suitable standard of care and accommodation for all service users.

CARE HOME ADULTS 18-65 Coppice Lodge 66 Walter Nash Road Kidderminster Worcestershire DY11 7BY Lead Inspector Dianne Thompson Unannounced Inspection 19th October 2006 10:00 Coppice Lodge DS0000018502.V316062.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 Coppice Lodge DS0000018502.V316062.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. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coppice Lodge Address 66 Walter Nash Road Kidderminster Worcestershire DY11 7BY 01562 637665 01562 861162 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) Mrs Faith Elizabeth Burgess Mr Trevor Burgess Mrs Faith Elizabeth Burgess Care Home 8 Category(ies) of Learning disability (6) registration, with number of places Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 04.01.2006 Brief Description of the Service: Coppice Lodge provides accommodation and personal care for up to eight younger adults with a learning disability. In addition, the home provides support for service users who may also present with behaviour that challenges. The home is an adapted house and is situated on the outskirts of Kidderminster town. All service users have single bedrooms, and there are ample communal areas and a garden. The home is owned by Mrs Faith Burgess and Mr Trevor Burgess and is managed by Mrs Burgess. Two senior staff supports Mrs Burgess. The fees range from £780.00 to £2,500.00 per week. Charges which are additional to the fee includes: • • • • • Personal toiletries, clothing and electrical items (TV and music centre). Activities not covered by the allowance made by the provider or in the funding authority contract Holidays Major extra outings Hairdressing Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Coppice Lodge. The main purpose of this inspection was to see what the service at Coppice Lodge was like for the people who lived there. Service user records were examined, and a tour of the building was also carried out. Accumulated information including notifications to the Commission for Social Care Inspection was used to inform this report. Time was spent with service users, staff on duty and the registered manager. What the service does well: Information is available about the services offered at the home to help people choose whether or not to live at Coppice Lodge and if the home will meet their needs. Service users are helped and supported to lead active and interesting lives at Coppice Lodge. They are also supported to stay in touch with their families and to develop friendships. The home offers a well-balanced diet and promotes healthy eating for the welfare of all service users. Personal and healthcare needs are written in care plans and provide information to make sure that care is provided in a way that service users like. The home has a medication policy and procedure to make sure that all medication is given and stored safely for the protection of service users and staff. The home’s complaints procedure has easy to understand information about how to complain. Staff support service users to have their say and to share any concerns they may have. Coppice Lodge is a safe, spacious and very comfortable home. The home is kept clean, tidy and well decorated. There are enough staff at the home, and the staff are trained to help them support service users. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home makes sure that suitable staff are employed and that all necessary checks are made to keep service users safe. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 6 The home is well managed with an open and positive approach. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coppice Lodge DS0000018502.V316062.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 Coppice Lodge DS0000018502.V316062.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): 1, 2, 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Detailed information is provided about the services offered at the home to help service users make an informed choice about whether they would like to live at Coppice Lodge and whether the home will meet their needs. EVIDENCE: The home’s statement of purpose and service user guide provides information about the home to help prospective service users to decide if they wish to live at Coppice Lodge. Copies of this information are available in a suitable format, which includes signs, symbols and photographs. Copies are accessible to all, including visitors to the home. A thorough assessment is completed for all new service users. The registered manager said that the home makes sure the needs of all service users can be met, that they wish to live in the home and that they are compatible with the current service users. The home’s assessment process is very detailed and the manager and service users care records demonstrate that the home receives full information about prospective service users, their background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 9 a range of sources including other relevant professionals, visits to previous homes or schools, and discussions with family members. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Care plans provide staff with detailed and relevant information about users assessed needs. They include risk assessments detailing how risks are to be reduced and independence promoted. Service users are encouraged to make choices and decisions in their daily lives and routines. EVIDENCE: Service user care plans are detailed and informative. The plans show monitoring of identified goals, and how these are to be facilitated and achieved. Staff have information to make sure that all care is provided in a preferred and consistent way that encourages independence. Comprehensive and detailed risk assessments are completed to cover all areas of potential risk to service users and the staff. The care-planning format shows that service users are appropriately supported to be involved in planning and reviewing their own care. Care plan reviews Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 11 take place regularly. Evidence was seen where identified changes to care and support have needed more care plan reviews, and these have been completed as required. Files for two service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in service user files to make sure all staff have the necessary information to provide quality care. Staff spoken to are fully aware of the plans and use them to guide their practice. Some service users have complex needs. Guidelines are in place, which promote the management of behaviour. These guidelines give clear indication of signs to look for, possible triggers to avoid and appropriate responses to use. There are signature sheets for staff to sign when they have been read and fully understood. The Commission for Social Care Inspection (CSCI) has received comments from two agencies, both commending Coppice Lodge and the staff team for the support and care they have provided to enable service users to manage their difficulties. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. EVIDENCE: The home provides a wide range of activities for service users, both in-house and within the local community. All activities are organised to take into account the individual needs and preferences of all service users, seeking to ensure everyone has the opportunity to participate. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 13 External activities include horse riding, visits to the railway station at Bridgnorth, bowling, drama group, drumming group, going to the pub, going for walks, drives out in the home’s vehicle, and shopping. Some service users are members of a local Advocacy group, which holds regular meetings and plan outings. One service user said he had been on a sponsored walk and raised some funds for the home. Some service users attend Kidderminster College for craft courses, and another service user attends the O’Dell social and recreational centre two days per week. Some service users attend Top Barn Nursery. This business provides employment opportunities in working with animals or in horticulture for people with learning disabilities. In house activities include being supported to do laundry, food shopping, household tasks, video nights, beauty sessions, and board games. Sensory activities that include the music room, tactile boards and lights, beanbags and music player are also available. Activities within the home also include watching TV and videos, listening to music, and involvement in daily routines. Holidays are organised for all service users. Cooking sessions include programmes which support service users to make their own lunch, help with the preparation and cooking of dinner, shopping for ingredients, making cakes, bread, and desserts. The home is invited to a Halloween Party with a disco, at its sister home nearby. The home is also invited to a fireworks party where family and friends are also invited. Family contact is encouraged and supported within the home. This includes talking on the telephone and visits to the home. The home offers a varied and healthy menu. Alternative choices are available as required. The balanced meals include fresh fruit and fresh vegetables. Lunch of gammon with roast potatoes, cauliflower cheese and vegetables was served during the inspection. Apple pie and custard was offered for dessert, with an alternative option available for those who preferred. Coppice Lodge DS0000018502.V316062.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 excellent This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are clearly identified in care plans. The plans provide information and make sure that care and support is provided in a way that service users prefer. The home has a clear medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users and the home are well supported by medical services, which includes GP’s, psychologist, dentist, community learning disability team, Occupational Therapy, Communication Team, Consultants (for epilepsy and orthopaedics), and support from the Intensive Support Team. Service users’ care records and plans provide detailed information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contained information about service users preferred personal care routines. The files are well organised. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 15 Information is regularly updated and clearly communicated, with all staff signing to say they have read and understand the information. Arrangements are in place for preventative health services, e.g. dental checks and annual health screening. Staff on duty said that all personal care is given in private to promote dignity for all service users. The home has a medication policy and procedure in place. Records are well maintained and hand written entries on Medication Administration Record forms have two signatures as a double check for accuracy. Entries in the daily records clearly indicate the reasons for any changes to medication. A list of all staff that have been trained and assessed to administer medication was seen. All staff have received first aid training. The administration of medication was observed during the inspection visit, and appropriate procedures were followed. Coppice Lodge DS0000018502.V316062.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. Service users are protected by the home’s complaints procedure that is available in easy to understand information about how to complain, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: There are suitable policies and procedures in place to support staff in keeping service users safe. The home’s complaints procedure is available in signs and symbols that make it more accessible for service users. The home has not received any complaints since the previous inspection report and there have been no complaints to the Commission for Social Care Inspection (CSCI). Compliments have been received by CSCI from two agencies involved with supporting the home, the Primary Health Care Trust and Intensive Support Team. Both compliments ‘commended the staff team for their consistency of approach, working with guidelines to support service users through a difficult time. Their commitment has seen an improvement in the quality of life for the service users concerned’. Throughout the inspection visit staff were observed engaging with service users in a supportive and respectful way. A limited time was spent with Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 17 service users, as they were being supported in various activities, including lunch and preparing for a ‘horse racing’ outing. Staff said service users are supported to ask for help or talk to staff if they have any concerns. All service users have key workers and with one exception all service users have relatives who give them support. Staff complete training in relation to abuse and service users’ protection during their induction and through specific training courses. Discussion in supervision and staff meetings also takes place. A poster advising on abuse issues is evident in the home. The home has relevant financial policies and procedures in place to make sure service users money is kept safe. Service users personal monies are obtained from a variety of sources, for example family and solicitors. All are well documented and receipted. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 18 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, 29, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Coppice Lodge provides accommodation for service users that meets their needs and offers a safe, spacious and very comfortable home. The home is kept clean to make sure that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: Coppice Lodge is located in a residential area of Kidderminster close to local amenities with access to the bus route into town. A tour of the home was completed. Coppice Lodge consists of a large kitchen, lounge, music room, bedrooms, individual bedrooms and sufficient bathrooms and toilets to meet the needs of all service users. The communal rooms are comfortable and well furnished and provide adequate space for shared activities. There is an enclosed garden to the rear of the property with easy access. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 19 The premises are clean and tidy and the kitchen has been refurbished. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Paper towels and liquid soap are available in the communal bathrooms. The garden has had a major refit since the previous inspection. The decked areas provide a sensory environment, and include tactile equipment with a variety of experiences. Walkways with different styles of lights, a water feature with lights, and seating areas have been incorporated into the design of the garden. Decorative handrails are provided for access and support around the garden. There is a grassed area decorated with flowerpots. A large trampoline with covered sides for added safety is available for service users to use. The manager said that two services users particularly benefit from using the trampoline. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 20 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, 36 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are being maintained and staff have received relevant training to help them meet service users needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The home is currently fully staffed, having recently recruited two new members of staff. The home does not use agency staff at the moment. Staff from one agency who are familiar with the home and service users will be used to if needed. To maintain consistency of care staff from one agency familiar with the home and the service users would be used if needed. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 21 The home has a committed staff team who work to provide quality care for the people living at Coppice Lodge. The home shows a commitment to staff training that is to be commended. For example, the home more than exceeds the requirement that 50 of all staff should be qualified to NVQ level. The home works to make sure that all staff complete NVQ training. An annual assessment of overall training needs is completed and a training plan is drawn up to meet those needs. Staff undertake mandatory health & safety training such as fire safety, first aid, food hygiene, moving & handling and infection control. Other training courses include communication, safe handling of medicines, and abuse. Details of a challenging behaviour training course that has been arranged is evident on the home’s notice board. The induction programme is accredited for people working in care services with people who have learning disabilities (LDAF). Induction also includes new staff being supported by senior staff to familiarise themselves with the home, service users and safety matters. The manager confirmed that all prospective staff complete an application form and that appropriate references are obtained including one from their most recent employer. An enhanced CRB and POVA (police) check is undertaken before their appointment is confirmed. Applicants are formally interviewed and invited to visit the home and meet service users. Service users are involved in interviews if they wish and evidence was seen where their opinions had been included. All staff have a copy of the terms and conditions of their employment and their own copy of the GSCC code of conduct and practice. All staff are required to work a probationary period at the home. The manager confirmed that all staff receive regular structured supervision. Time was spent with a new member of staff, three weeks into their post. It was confirmed that he is currently completing his induction and shadowing other staff. The member of staff said he has spent time reading files, policies and procedures. This was observed during the visit. He said he has been welcomed into the job, feels well supported and is comfortable asking questions or for help. It was confirmed that the homes recruitment policies and procedures had been followed and that all the required checks had been completed. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 22 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, 43 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is well managed with clear lines of accountability. A committed staff team supports the registered manager. Together they provide a well-run service, in a setting, which safeguards service users and maintains their rights. An experienced and committed manager who has an open and positive approach manages the home. Through their quality assurance system, the provider and manager monitor the home to make sure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 23 The registered manager Faith Burgess, has undertaken a range of training relevant to service users needs. It is evident she is knowledgeable about learning disabilities and the implications for service users themselves and their care. Management responsibilities in the home are shared with two senior support staff. The manager and deputy are involved in organising day-to-day activities, health & safety promotion, staff supervision and induction. Staff confirmed the manager is approachable and said that service users are always put first. They say the staff team works closely together to support service users and to make sure that all their needs are met. Records seen show that regular checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff complete all mandatory health and safety training topics. Maintenance and repairs are dealt with promptly. The home’s annual Quality Assurance review has been completed. A copy of the development plan has been sent to CSCI, and identifies areas and the timescales for the proposed developments. Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 4 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 3 Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Coppice Lodge DS0000018502.V316062.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Coppice Lodge DS0000018502.V316062.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. 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