Inspection on 15/11/05 for The Coppice

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Coppice 13/04/07

The Coppice 29/06/06

The Coppice 04/05/05

The Coppice 17/02/05

The Coppice 05/04/04

The Coppice 11/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Coppice 51 Wellington Road Altrincham Cheshire WA15 7RQ Lead Inspector Helen Dempster Unannounced Inspection 15th November 2005 12:30 The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Coppice Address 51 Wellington Road Altrincham Cheshire WA15 7RQ 0161 929 4178 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) Elizabeth Fitzroy Support Care Home 7 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual currently accommodated has a learning disability and is also over pensionable age. 4th May 2005 Date of last inspection Brief Description of the Service: The Coppice is a detached brick built property and is in keeping with others in the road. The home provides accommodation with personal care for 7 people with a learning disability. It is situated near to a local school and there are traffic calming measures in the area. The house is divided into two properties with an inter-connecting door. The main body of the house provides accommodation for five residents. There is a semi-independent living arrangement for two male residents in the annex. There are large secluded rear gardens and parking. The laundry facilities for the home are situated in the detached garage at the rear of the property. The home has its own minibus, which affords the residents access to day care, local colleges, recreational facilities, and places of interest. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second unannounced visit for the year, which took place from 12.30pm to 6.30pm on 15th November 2005. The visit focused on care planning, residents’ experiences of living at the home, the management and staffing arrangements and the environment. The term of address preferred by the users of the service was confirmed as ‘residents’. It was felt that this best reflected the function and purpose of the service. The inspection did not look at all the standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? The residents needs were assessed and recorded in detail, were linked to the care plan and reflected the residents’ views on the way their needs should be met. The staff had also worked hard to develop person centred care plans which clearly recorded residents’ choice in the way their care was delivered. Risk assessments had been developed to make sure that residents are involved in the day to day running of the home. Overall, medication practice had improved. This included having patient leaflets for the medication administered by the staff and keeping accurate stock records of medication. The adult protection systems in the home ensured the safety of residents from abuse. Residents’ worries and concerns were listened to and taken seriously. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 6 Staff morale, training and supervision had all improved. The home had a new manager and were also about to have a new assistant manager. The fire risk assessment had been reviewed and fire drill practice had improved. 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 Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Information, in writing, about the home was provided to prospective residents and their needs were assessed and documented in detail. EVIDENCE: In response to a requirement made at the previous inspection, the home’s Statement of Purpose and Service Users Guide had been revised so that they provided necessary information to current and potential residents and their advocates. The needs assessment for each of the 7 residents had been revised in response to a requirement made at the previous inspection. These needs assessments were clear and detailed and reflected the residents’ views on the way their needs should be met. This is good practice. The needs assessment for each resident made reference to their support plan, yet these documents were not held together in the file in day to day use. It was recommended that these documents were held together for ease of cross-reference by the staff. . The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 The residents benefited from having person centred care plans which clearly recorded residents’ preferences in the way their care was delivered. However, this good practice did not extend to the review of care plans and risk assessments. This weakness compromised the staffs’ ability to meet the changing needs of residents. EVIDENCE: At the previous inspection, conducted in May 2005, only one resident had a care plan. During this inspection it was evident that a great deal of work had been completed immediately following the previous inspection in response to requirements made at that time. In particular, the following action had been taken to meet requirements: • All 7 residents had a detailed care plan, written with their involvement, in a person centred manner, which highlighted their wishes and preferences on the way their care is delivered. Care plans included details of needs and there was a link to the assessment of needs. DS0000005606.V263442.R01.S.doc Version 5.0 Page 10 • The Coppice • Care plans had been developed to include details of specific mental health conditions and support provided by staff, including the procedures and protocols used by the home in the management of aggression for the resident to which this was relevant. Seizure patterns were documented for those residents for whom this was relevant. Residents social, leisure and community based needs and activities had been identified and recorded in individual care plans. • The changes in care plans were completed in May 2005. However, what was of concern was that they had not been reviewed since that time. The senior manager present during the inspection said that the home was about to introduce ‘Reach standards in supported living’, which included a format for reviewing care plans. However, it was stressed that the requirement made at the previous inspection to the effect that care plans must be reviewed on a regular basis should have been addressed by June 2005. This requirement was repeated and must be actioned without further delay. Requirements were made at the previous inspections concerning risk assessments. These had been addressed concerning the residents’ participation in the day-to-day running of the home. Manual handling risk assessments had also been completed to reflect the specific handling requirements of individual residents and they specified the aids and equipment used by the residents. Good practice was evident in that these assessments covered bathing, swimming, getting into vehicles and walking. Pictures were also used to provide guidance to staff in supporting individual residents to mobilise. For one resident, risk assessments were also in place to address the risks inherent in all aspects of daily living. However, this process hadn’t been undertaken for all the residents and the requirement made at the previous inspection was repeated. Those risk assessments, which were in place had not been reviewed for some time. A further requirement was made to the effect that risk assessments are reviewed on a regular basis. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15,16 and 17. Residents were benefiting from being offered the opportunities and support that they required to access appropriate social, leisure and community based activities. However, this good practice was compromised by residents not always being offered a choice of meals. EVIDENCE: The service did offer the opportunities and support for residents to access appropriate social, leisure and community based activities. Since the previous inspection, the home had introduced ‘listen to me’ books as part of the person centred planning process. These recorded each resident’s social needs, preferences and likes and dislikes, including food. Some residents continued to attend the organisation’s day care service and had the opportunity to be supported to access social and leisure activities either in the home or the community. Within the home, people had access to the television and music. Staff used the home’s minibus to support residents to access activities in the community. Residents’ rooms were personalised. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 12 There was an open visiting policy at the home and residents were supported to maintain relationships with family and friends. The manager explained that the staff team talk to residents about food each week so that they can informally plan menus. One resident’s care plan stated that he didn’t like spicy food and he had not enjoyed the meal at the time of inspection. The need for alternative choices to be offered and consultation with residents about what they want to eat to be recorded was discussed and a requirement was made accordingly. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Residents’ preferences about the way they wished to be supported were respected and health care monitoring arrangements had improved. However, errors in recording administered medication had the potential to compromise the residents’ well being. EVIDENCE: All interactions between staff and residents were observed to be sensitive and respectful of their rights and care plans recorded individual resident’s preferences on the way they wished to be supported by staff. In response to a requirement made at the previous inspection, arrangements for the monitoring of residents’ health had improved by all residents receiving an ‘OK’ Health Check in May 2005. Overall, medication practice had improved in response to requirements made at the previous inspection. In particular, patient leaflets for the medication administered by the staff had been obtained from the pharmacy and stock records of medication were accurate. However, at the time of inspection, some gaps in the medication administration records were seen where medication appeared to have been administered but the record had not been signed accordingly. The frequency of such human error had decreased since the previous inspection, but the manager needed to develop a procedure for The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 14 identifying such errors and obtaining an explanation from the staff member concerned without delay in the interests of residents’ safety. A requirement was made accordingly and a requirement from the previous inspection concerning having a clear audit trail for all medication was repeated and must be actioned without further delay. Care plans were in use for the administration of Paracetamol, which is good practice. However, a further requirement was made to the effect that a care plan for the administration of all medication, including ‘when required’ (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given must be in place for each resident. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home ensured that the residents were listened to, their concerns were acted upon and that they were protected from abuse. However, staff needed to be trained in managing complaints to ensure that the good practices seen were not compromised. EVIDENCE: A requirement made at the previous inspection to the effect that any complaint made under the complaints procedure must be fully investigated and a detailed record must be kept in the home of the investigation and outcome of complaints and concerns raised by the residents and their families had been addressed. A further requirement made to the effect that the manager and staff must receive training in dealing with complaints had not been addressed and must be actioned without further delay. Requirements made at the previous inspection to the effect that staff must familiarise themselves with Trafford Local Authoritys Adult Abuse Procedure had been addressed. Furthermore, all staff had attended training, which included specific guidance in the implementation of Trafford Local Authoritys Adult Abuse Procedure. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The poor level of hygiene at the home and fittings and fixtures in a state of disrepair were weaknesses which compromised residents’ comfort, dignity and safety. EVIDENCE: A tour of the premises was conducted and most of the residents’ bedrooms were seen, accompanied by the resident where possible. In response to a requirement made at the previous inspection, the contents of all the bedrooms had been audited and shortfalls noted on the individuals personal plan. However, at the time of the visit, residents’ bedrooms were found to be in a poor state of hygiene and in some cases in a poor state of repair. In particular, the carpets in some rooms were badly stained and in need of cleaning or replacement. One resident’s curtains were hanging off the pole, which did not respect her privacy and dignity. Paintwork in bedrooms was dirty and some bedrooms had damaged furniture, including a missing wardrobe door and broken cupboards and drawers. The ground floor toilet and bathroom were dirty and broken shower screen was propped against the wall near the toilet. There was a smell of urine in a The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 17 lounge area. The manager and senior manager’s attention was drawn to the state of the premises. When she saw the dirty and broken shower screen the senior manager said that she felt “ashamed”. Carpets throughout the home needed hoovering. The manager and senior manager acknowledged that the above issues were unacceptable. A requirement was made accordingly and monitoring visits will be conducted to ensure that these issues are addressed. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 36. Staff morale had improved and staff were receiving management support, supervision and training. However, the staff team were not receiving some key training, which had the potential to impact negatively on the welfare, health and safety of residents. EVIDENCE: At the previous inspection, staff morale was low and they said that they lacked leadership. At the time of this inspection, staff morale had improved and the staff were on a teambuilding training day to assist this process. At the start of the inspection, the home was staffed with 2 agency staff, one of whom had worked at the home for some time and had applied for a permanent post there. The manager and a senior manager came to the home to take part in the inspection. There were 3 staff vacancies at the time of inspection totalling 90 hours. The home was in the process of recruiting to these posts. At the previous inspection, a requirement was made to the effect that an audit of staff training must be completed and consistently reviewed to ensure that staff were able to meet residents individual and joint needs. This had been addressed, but on viewing the audit it was apparent that for some staff, including the manager, mandatory training, including food hygiene and manual handling, was in need of updating. A requirement was made accordingly. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 19 At the previous inspection, a requirement was also made to the effect that staff should receive the support and supervision to carry out their jobs, which must include at least 6 supervisions per year and an annual appraisal. This had been addressed by planning a program of supervision and appraisals. The senior manager stated that staff have blocks of training, which includes the LDAF basic introduction and foundation training. One staff file sampled documented attendance on this training. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43. The residents’ welfare had improved by the organisation making positive changes. However, more consistent and careful monitoring and reviewing of the management systems were necessary to ensure that residents continued to benefit and that their safety and welfare did not become compromised. EVIDENCE: Just prior to the inspection, the organisation had completed the recruitment procedure for the manager of the home. The former acting manager had been appointed and the organisation were about to apply to CSCI for her to be the registered. The manager’s interactions with residents and staff were observed and found to be appropriate. She appeared to have a good rapport with residents and staff and expressed her commitment to continuous improvement at the home. The senior manager also expressed her commitment to actively supporting the new manager. It was required that the manager update mandatory training and it was strongly recommended that she commence study towards NVQ level 4. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 21 It was clear that the organisation had made many positive changes to address the concerns and subsequent requirements made at the previous inspection. However, while improvements were considerable, this needed to be sustained as some aspect of practice e.g. the hygiene level at the home, had slipped and there was a lack of continuous review of all aspects of practice, including care plan records. Follow up visits will be made to the home to ensure that further improvements are made and sustained. At the previous inspection, a requirement was made to the effect that health and safety procedures were reviewed to include completing fire drills consistently and ensuring that records provide any details of the service users involvement, the type of drill, the staff and service users response and the time taken. This had been addressed by reviewing the fire risk assessment and improving fire drill practice and good practice was evident in the use of clear guidelines about the support of each individual resident in the event of fire and evacuation. However, it was disappointing to note that while fire safety checks of the fire alarm and means of escape had been consistently made previously, there were some gaps in the records of fire alarm tests (which, on occasions, were done every 2 weeks instead of weekly) and the checks of the emergency lighting needed to be made each month. The home also needed to consistently list participants in fire drills. Immediate requirements were made concerning these issues. The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 1 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Coppice Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 2 2 X X 2 2 DS0000005606.V263442.R01.S.doc Version 5.0 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 Risk assessments concerning risks specific to all aspects of the individual service users personal care should also be linked to the care plan. Risk assessments must include clearly documented guidelines for staff and must be in place for all 7 residents. (Previous un-met timescale 9/05/05). Care plans and risk assessments must be reviewed on a regular basis, and a documented review of care must be undertaken every 6 months. (Previous unmet timescale 9/06/05). Essential life style plans must be further developed so that any limitations to the rights of residents are justified through a risk assessment process. (Previous un-met timescale 9/06/05). Alternative menu choices must be offered and consultation with residents about what they want to eat must be consistently recorded. DS0000005606.V263442.R01.S.doc Timescale for action 02/12/05 2 YA6 15(1) 02/12/05 3 YA7 15 02/12/05 4 YA17 16 02/12/05 The Coppice Version 5.0 Page 24 5 YA20 13 6 YA20 13 7 YA22 22(2)(3) and 18 23 8 YA24 9 YA30 23 10 YA35 18 11 12 YA37 YA38 18 18 and 24 13 YA39 24 Medication procedures must be reviewed so that a safe system of medication administration is consistently in place with a clear audit trail for all medication. (Previous unmet timescale 11/05/05). A care plan for the administration of all medication, including when required” (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given must be in place for each resident. Staff must receive training in dealing with complaints and customer care. (Previous unmet timescale 20/06/05). An audit of damaged fittings and fixtures and badly stained carpets must be undertaken and repairs/cleaning/replacement arranged as appropriate. The premises must be thoroughly cleaned and a hygiene audit must be put in place to ensure that an acceptable level of hygiene is consistently maintained. Mandatory training, including food hygiene and manual handling, must be updated for those staff for whom it had lapsed. The manager must update mandatory training, which had lapsed. Management arrangements at the home must be consistently monitored to ensure that CSCI requirements are met within timescales. (Previous unmet timescale 9/06/05). Quality assurance systems in the home must be reviewed and updated so that the existing DS0000005606.V263442.R01.S.doc 02/12/05 02/12/05 25/02/06 02/12/05 02/12/05 25/01/05 20/12/05 02/12/05 25/01/06 The Coppice Version 5.0 Page 25 quality assurance manual is put into practice. This should incorporate service user satisfaction questionnaires, and the views of family, friends and advocates and stakeholders within the community on how the home is achieving goals for the service users. (Previous unmet timescale 20/06/05). 14 YA42 23 Weekly fire safety checks of the means of escape and fire alarm must be consistently made and recorded. Monthly tests of the emergency lighting must be consistently made and recorded. Fire drill records must list participants and note the response time of staff. 15/11/05 15 YA42 23 15/11/05 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 1 Refer to Standard 2 37 Good Practice Recommendations The home should consider holding the needs assessment for each resident with the support plan in the file in day to day use, for ease of cross reference by the staff The organisation should support the new manager to commence her study towards the registered managers award (NVQ level 4). The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 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 The Coppice DS0000005606.V263442.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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