Inspection on 20/02/07 for The Copse

This inspection was carried out on 20th February 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Copse 03/12/07

The Copse 19/04/06

The Copse 03/10/05

The Copse 07/04/05

The Copse 11/10/04

The Copse 14/06/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Copse Beechmount Close Old Mixon Weston Super Mare North Somerset BS24 9EX Lead Inspector Justine Button Unannounced Inspection 20th February 2007 09:30 The Copse DS0000020375.V322650.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 The Copse DS0000020375.V322650.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. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Copse Address Beechmount Close Old Mixon Weston Super Mare North Somerset BS24 9EX 01934 811448 01934 811352 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) Shaw healthcare Limited Mrs Terina Noke Care Home 24 Category(ies) of Learning disability (24), Learning disability over registration, with number 65 years of age (24), Physical disability (14), of places Physical disability over 65 years of age (14) The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 24 Adults, aged 18 and over, with Learning Difficulties which can include 14 Physically Disabled Persons Manager must be a RN on Parts 3, 5, 13 or 14 of the NMC register Staffing levels as detailed in the Notice of Registration dated 1st September 2004 apply Date of last inspection Brief Description of the Service: The Copse is care home with nursing for younger adults with learning disabilities and physical disabilities. It is situated on the outskirts of Weston super Mare. The home is arranged into four small units each with their own communal areas. The residents at the home can also access a minibus. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted to monitor the progress made towards meeting the requirements and recommendations made at the last key inspection. The last key inspection was conducted in April 2006. At this and the inspection conducted in October 2005 a number of issues of concern were raised. Since April 2006 the CSCI has monitored the service by conducting frequent unannounced random inspections. Reports of these visits are available on request. The CSCI have also had a number of meetings with the provider, Shaw Healthcare LTD, and Social Services. Since April 2006 the management of The Copse have worked hard at addressing the shortfalls and the service is no longer a home of concern. Although a number of shortfalls have been addressed and the provision of care and support has improved continued work is required to ensure that these improvements continue. This inspection was conducted over the course of one day by one inspector. The manager was available throughout the inspection. The inspector would like to thank the people living at the home and staff for their help and support in this inspector. What the service does well: The service is designed in four separate living areas or “flats”. This allows for a domestic feel within the home. Each “flat” has it’s own bedrooms, bathrooms and living area. This does not prevent people living at the home visiting other areas if they wish. Since the last key inspection some environmental changes have been made to each of the “flats” to meet the needs of the group of people living within that area. One living area has been developed for people with sensory impairments and another for people who are more independent. Some areas of the home have been decorated. This has been competed to a good standard .One living area and corridor now have a large amount of tactile and visually stimulating decorations. The home has developed a multi sensory area and a therapy room used for reflexology. On this inspection interactions between people living at the home and staff were positive. People living at the home appeared animated and interested in the activites that were available within the home. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 6 The home has developed accessible information in the form of a DVD. This will be used for people interested in moving into the home particularly for those who cannot access written information. What has improved since the last inspection? What they could do better: Although some environmental changes have been completed some issues remain. One “flat” is used by wheelchair users. People living in this area who use wheelchairs cannot independently access their bedroom from the lounge and visa versa due the doors, which are domestic in nature. Consideration should The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 7 be given to installing automatic or mechanical door opening in this area. The bedrooms are not large. Consideration should be given to the fitting of overhead tracks and hoists in bedrooms where people have mobility issues. This would maximise the space available. The service has a small garden around the building. This garden is not sufficiently large to accommodate large numbers of people in the summer months. There is a large roof garden, which is directly accessible from two of the “flats”. The flooring in this area however is unsafe with uneven flagstones, which are extremely slippery when wet. This flooring requires replacement to ensure that people living at the home have accessible outdoor space. Consideration should be given to completing this work over the next few months so that it is completed before the warmer summer months. Although a number of areas have been redecorated some additional decoration is required. This is particularly required in some of the corridors and in the living areas of the flats “Aspen” and “Tamarind”. Two of the bathrooms require updating and redecoration. Although interactions between staff and people living at the home have improved it is evident that staff need to develop skills in communication particularly non-verbal communications. This will ensure that the positive relationships between people living at the home and staff continue to develop. Improved communication will ensure that people living at the home have the opportunities to influence the way the home is run and to ensure that they have meaningful choices. 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. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has developed some accessible information about the home. People considering moving into the home have the opportunity of visiting the home. Staff from the home complete a preadmission assessment to ensure that the home can meet the individuals needs before they move into the service. EVIDENCE: The home has recently completed a DVD, which provides people thinking of moving into the home with information. This is in addition to a service user guide and statement of purpose. The guide has pictures relating to the home and the facilities the home offers. The range of information available should now be accessible to the majority of people. The home currently has four vacancies. One person is due to move into the home over the next few weeks. This individual had been visited by at least The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 10 two staff members on a number of occasions. The individual was also due to visit the home. The purpose of these visits is to meet additional staff, the people living at the home and to become familiar with the building. These transitional arrangements ensure that all parties are happy to proceed with the placement and to ensure the home can meet the individuals needs. Contracts were not viewed on this occasion. These were inspected in the last key inspection conducted in April 2006 when it was reported “The residents all have a contract pertaining to the terms and conditions of occupancy at The Copse. The contract is standard and is not accessible to residents. The inspector discussed the contract with the manager who is currently identifying the local authority responsible for each resident and their review of provision. For some of the residents the specific needs have changed since admission, and this may be an opportunity to seek additional funding for one-to-one support for those residents with very complex needs and minimal day-care funding.” The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning process has significantly improved. Systems are being developed to enable people living at the home to contribute and participate in life at the home. EVIDENCE: Following requirements made at the April 2006 staff have worked hard at improving the care planning process. Five plans were viewed on this occasion. People living at the home now have a file containing all the necessary assessments and care plans. The health plans contained a range of physical assessments relating to nutrition, pressure sore risk, moving and handling and the risk of falls. Subsequent plans of care detailing support needs have been formulated. These The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 12 plans gave clear guidance to staff on the support needs of the individual. The plans are now reviewed at regular intervals and changing needs are reflected. A number of people also have health passports. This is a small document, which describes the individuals basic physical support needs. This document is used for example if an emergency admission to hospital is required to provide information to the hospital staff. Occupational aspects/activity plans are also in place. These plans are now more person centred than those seen on previous inspections. The majority of people living at the home have reduce or no verbal communication. There are currently few staff who have received training or with the ability to communicate by other methods. This currently limits the opportunities for people living at the home to express choices, aspirations and to have the opportunity to have involvement in the development of their plan. The manager stated that she was aware of these shortfalls and a number of systems were currently being developed. Staff are currently working with one service user by using pictures of a bath or shower and of a glass of cold juice and a cup of tea. By pointing to the picture of the bath/shower or cold/hot drink the individual is able to make his choices known. This work is currently at an early stage and it is hoped that additional choices in other areas will be added in the near future. It is also hoped that these choice cards could also be used for other individuals at the home. In one of the “flats” people living at the home are now working with “People First” an independent advocacy group for people with learning difficulties. People first are supporting the people living in the flat to develop service use meetings. This will ultimately allow the people living in the flat to express their opinions on the care and support provided and what improvements they would like to see. It is hoped that this support will be extended to the other “flats” within the home allowing all people the opportunity to participate in this way. There is currently limited or no information in accessible formats providing information to the people living at the home e.g. which staff are working that day, what is on the menu for meals, what activites or social opportunities are available for that day. If the home is to continue to develop and improve the support and care available they must now ensure that communication methods, applicable to the people living at the home are developed. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14 16, 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The opportunities for personal development and activites has improved with people living at the home having increased access to the local community and leisure activites. People living at the home have their rights respected although this area could be further developed with an increase in communication systems. The home provides a healthy diet. It cannot be confirmed if active choices are available to all people living at the home. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 14 EVIDENCE: Historically social and recreational activity support for people living at the home was provided by an outside agency, The Brandon Trust. Support from the trust was typically from 9-3 Monday to Friday. This arrangement did not allow for people living at the home the opportunity or choice to access activites or social events outside of these hours. Since the last key inspection in April 2006 the arrangement with Brandon Trust has been reviewed. Although the support from the trust typically continues to be 9-3 Monday to Friday there is now an agreement that if required staff from Brandon Trust will offer support outside these hours. In addition the culture from staff at the service has changed. Previously staff appeared reticent to support people in social and recreational opportunities. This culture has changed with staff at the service now more proactive in supporting people in this area. This includes supporting them in the community. There is an increase in social and recreational opportunities within the home. A therapy room has been developed. This is used by the visiting aroma therapist and is enjoyed by a number of people but particularly those with sensory impairments. A sensory room has also now in place in one of the “flats” although this can be accessed by anybody living at the home. Staff reported that this area was well used and enjoyed by a number of people. On the day of this inspection people living at the home were seen going to day care with Brandon Trust staff, listening to music, watching TV, completing arts and crafts, three of the ladies were seen having a manicure and some people were enjoying the sensory area. Interactions between staff and people living at the home were positive and appropriate. As previously stated the development of communication methods would ensure that these relationships continue to develop and that people living at the home have choices about social and recreational opportunities. The meal on the day of the inspection was seen. The menu held in the office stated that two choices were available. During the inspection however all people living at the home ate the same meal, pork in sauce with mashed potatoes and vegetables. Due to lack of communication methods it was difficult to assess if people had made an active choice about what they wanted to eat. Staff stated that they were aware of peoples preferences as they knew everybody well and were aware of which foods they had enjoyed in the past. The staff and management have to develop systems to allow choice to take place. This could be offering the two plates of food or developing a range of photographs, which would allow people to make active choices. The development of photographs could be used to display the menu prior to the meal being served. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 15 Staff supported people, who required it, in a dignified way and positive interactions were observed. The quality of meals provided at the home has improved with a reduction in the use of pre prepared and packaged products. There is now more emphasis on using fresh ingredients and homemade meals. There was a range of fresh fruit on each of the “flats”. Staff stated they used the fruit to make smoothes on a daily basis. Each “flat” has a small kitchenette area, which enables snacks and drinks to be prepared. On the day of the inspection all the people at the home appeared to enjoy the meal. Those who were able to give an opinion stated that the meal was nice. Take away meals are purchased on occasions at weekends. A number of people have also been supported to go out for meals to pubs and restaurants The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for the administration, storage and documentation have improved. Services users health and emotional needs are met. EVIDENCE: As previously stated all people at the home have a plan of care detailing their care and support needs. It is difficult to assess if care is delivered how the individual would want it to be delivered due to the lack of communication tools available and individuals input into the care plan. Discussions with staff however demonstrated that there is now a more person centred and individualised approach to meeting the care and support needs of the people living at the home. All the people living at the home appeared well kempt on the day of the inspection. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 17 People living at the home are now accessing health professionals such as GP or dentist in the community. This has help change the culture and reduced the institutional feel of the home. The care and support plans in place demonstrated that people access health care professionals as required. Medication was viewed during the inspection. Previous issues, which culminated in a number of drug errors, appear to have been resolved. The procedures for the storage, administration and documentation of medication have been reviewed with practise now in line with best practise guidelines. The management at the home now ensure that all staff who deal with medication, including agency staff, are aware of the procedures and disciplinary action is taken if these guidelines are not adhered to. On the day of the inspection the Medication Administration Records were viewed. On the whole these were well maintained. Two people however had hand transcribed entries. It is good practise that any entries made in this way are countersigned by a second person to ensure that the correct medication and dosage has been made. This was not seen in these two cases. The manager agreed to implement this following the inspection. Stock levels at the home were adequate. The drug fridge temperature was recorded and was within safe limits. The management conduct regular audits relating to medication. No people at the home are currently self-medicating. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It cannot be confirmed if people’s views are listened to to the fullest extent. Complaints and concerns are dealt with appropriately. All staff has now received training on abuse awareness. Recruitment procedures are robust. This ensures that people living at the home are protected from abuse, neglect and self-harm. EVIDENCE: Concerns raised in late 2005 and early 2006 to both the CSCI and social services culminated in a range of multi agency meetings being conducted under the remit of protection of Vulnerable Adults. Several staff were disciplined under the companies disciplinary procedure. Since this time the management structure at the home has changed and the majority of issues resolved. A number of new staff have been recruited and all staff have received training in the prevention and recognition of abuse. Staff spoken to during the inspection stated that the feel at the home had changed and there was now a culture of empowerment for the people living at the service. Staff recruitment procedures are robust. Since the initial concerns were raised an additional two anonymous concerns have been received by the CSCI. These concerns related to the provision of food and the management at the home. These concerns were investigated by The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 19 the CSCI and not substantiated. An additional complaint has been received and investigated by Shaw Healthcare. This complaint was investigated in line with the company’s complaint procedure. Relatives meeting have been introduced. The last meeting was held in January 2007. This has enabled interested parties to raise concerns that they may have and also influence the running of the home. Given the lack of communication systems at the home it could not be confirmed if people living at the home would have the opportunity to express any concerns that they may have. The planned introduction of communication methods and meeting for people living at the home will go some way to addressing these shortfalls. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment at The Copse has improved although further improvements are required to promote independence and safety. Communal areas are organised into four separate “flats” which are domestic in nature. Bedrooms are personalised. The service is clean and tidy. EVIDENCE: A tour of the building was conducted during the inspection. A number of areas have undergone refurbishment since the last key inspection. The home is organised in to four “flats” two on the first floor and two on the ground floor. Previously people had to go through the lounge of one flat to reach the stairs and lift to access the upper floor “flat”. Works have been The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 21 completed to rectify this issue with each “flat” now has it’s own entrance. This has ensured that the privacy of people living in one area is not compromised. A number of areas have been redecorated. In one flat the corridor has been decorated. Tactile and sensory additions have been made which have made the corridor very appealing. Staff should be commended for their work in completing this area. Hand and grab rails have been lowered in on area allowing all people to have access to this equipment. A number of other areas have been redecorated and new carpet laid. Although some improvements have been made some areas require updating and refurbishment. A number of the bedrooms are not large and some accommodate people who are wheelchair users. Consideration should be given to fitting overhead tracking hoists to maximise the room available. People who use a wheelchair cannot independently access the doors from the lounge area to the bedrooms and visa versa. Consideration should be given to installing automatic or accessible doors in this area. The flat roof garden area is unsuitable as the floor is uneven and slippery therefore presents a trip hazard to any persons using this area. The ground floor gardens are small so there is limited accessible outdoor space. A number of people living at the home enjoy the opportunity of sitting and socialising outside in the warmer weather. The roof garden needs to be repaired to allow all people at the home the opportunity of accessing this space. The front door to the building has an automatic door. This door is not linked to the fire alarm system. It could not be confirmed how this door would be opened in the event of an emergency. Given the close proximity to both the kitchen and laundry this matter needs to be reviewed as a matter of urgency. Advise from the fire officer may be required. This should be reflected in the homes fire risk assessment. Although a number of areas have been redecorated some additional decoration is required. This is particularly required in some of the corridors and in the living areas of the flats “Aspen” and “Tamarind”. Two of the bathrooms require updating and redecoration. All areas of the home, including the kitchen and laundry were clean and tidy on the day of inspection. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are aware of their roles and responsibilities. A range of training is available although both people living at the home would benefit from staff having increased skills in communication. The homes recruitment procedures are robust. A system of staff supervision and appraisals is now in place. EVIDENCE: The staff rotas were viewed during the visit and these demonstrated that adequate numbers of staff were available. Staff spoken during the inspection stated that they felt that staffing levels were adequate. Two new staff members discussed their induction and stated that they had felt well support through this process. Staff stated that training opportunities were available at the home and felt that this had contributed to the improvements made at the home. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 23 All staff have or are completing Learning Disability Awards Framework (LDAF) as part of their on going training. Other training has included • Health action plans • Medication administration. • Autism awareness • Dementia and challenging behaviour • Values and atieology of learning disability In addition two staff have completed training in positive communication. These staff are taking the lead in developing communication system at the home. This training should be extended to more staff to ensure that effective communications methods are introduced for all people living at the home. A staff training matrix is in place. This documents all mandatory training. All working staff have received training in mving and handling, fire and recognision and prevention of abuse. Ancillry staff have received training appropriate to their job role. Staff spoken to during the inspection were clear about their job roles and responibilites. They described their role as one which was supportive and enabling. One staff member stated that “everybody is treated as an indivdual. This includes people living at the home and staff” Staff recruitment records were viewed for four staff who has recenetly been employed. All necessary checks are completed including Criminal Record Bureau and Protection of Vulnerable adults. Some staff had commenced employemtn prior to the CRB check being returned however these staff were working under supervision and completing the induction programme. Two writen refeences are obtained, one of which is from the last employer. This is in line with good practise guidelines. A system of staff supervison has been implemented. Staff also receive annual appraisals. Staff stated that they apprechated this support. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has improved since the last key inspection this is due to a strong management structure at the home. It cannot be confirmed that service users views underpin the development of the home due to the lack of communication systems. These systems are currently being developed. The health, safety and welfare of people living at the home are promoted and protected. EVIDENCE: The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 25 During the inspection the manager completed an initial tour of the building with the inspector. During this time it was evident that Ms Noke had a positive relationship with the people living at the home. Staff also confirmed that they found the management approachable and open to ideas. The home has made improvements over the last few months and this is due to a strong managerial team, which has been built up at the home, including a strong deputy manager and senior staff team. All staff need to be encouraged by the improvements made and continue to develop the service. A series of meeting are now held including regular staff and relatives meetings. These enable all people to express their views. As previously stated it is hoped with the work of People First that these will be extended to all people living at the home in the near future. During the day of the inspection the service was being assessed for the investors in people award. A range of maintenance records were viewed and these showed that on the whole the home is well maintained. A number of issues still remain as detailed previously in this report. The home and senior managers of Shaw Healthcare complete a series of audits and self-monitoring. These ensure that the home identifies areas that require work and ensure the continued development of the service. The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 2 25 3 26 3 27 2 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 2 3 3 3 3 The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 27 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 YA24 Regulation 23 Requirement The home should have an action plan to improve accessibility for disabled people to include accessible doorways and outdoor space. (Previous timescale of 24/05/06 not met). The home develops systems for communicating effectively and consulting with residents so they have more influence in the dayto-day running of the home. (Previous timescale of 24/05/06 not met). The home should develop staff training to ensure that staff have the skills and competences to communicate effectively with service users. The management keep the environment under review such that the premises are of sound construction and kept in a good state of repair. This should include the bathrooms. The home develops systems for communicating with service users so that they can make DS0000020375.V322650.R01.S.doc Timescale for action 04/04/07 2. YA38 16,24 04/06/07 3. YA32 18 (1) (a) 04/06/07 4. YA24 23 (2) (b) 04/06/07 5. YA7 12 (3) 04/06/07 The Copse Version 5.2 Page 28 active choices and so far as practicable ascertain and take into account their wishes and feelings. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA42 Good Practice Recommendations It is recommended that the management ensure that the automatic door at the front of the building can be opened in the event of an emergency. Any remedial action required should be taken to It is recommended that all hand transcribed entries on the Medication Administration Record be checked and counter signed by a second person. 2. YA20 The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 The Copse DS0000020375.V322650.R01.S.doc Version 5.2 Page 30 - 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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