Inspection on 03/12/07 for The Copse

This inspection was carried out on 3rd December 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Copse 20/02/07

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 Jill Cornelius Unannounced Inspection 3 December 2007 10:00 rd The Copse DS0000020375.V352339.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.V352339.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.V352339.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 Ltd 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.V352339.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 20th February 2007 Date of last inspection Brief Description of the Service: The Copse is care home with nursing for 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.V352339.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 of 20th February 07. This inspection was undertaken on one day. Information was gathered from Annual Quality Assurance Assessment (AQAA) competed by the manager and returned by 16/10/07. The CSCI sent out 16 ‘Have your say’ surveys, 5 were returned and comments from these are included in the body of the report. 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: Comments made in survey returns; ‘ Everyone at the Copse make it possible for my relative to have a happy, safe fulfilled life. Its like one big family there’. ‘If all care homes were as good as the Copse you people would be out of a job’ ‘ There is always room for improvement. The Copse always try to do things to the best of their ability with the funds they are given. ‘ Provides a clean hygienic and caring environments. Also allows for spontaneous visits’. 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. 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 activities that were available within the home. 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. The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 6 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. The Copse DS0000020375.V352339.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 The Copse DS0000020375.V352339.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, 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 a completed 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. Comments from AQAA include: ‘We endevour to provide an indepth transition plan for all prospective service users using accessable information and DVD’s of the home’. The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 9 However the manager stated these are currently under review due to the environmental changes undertaken this year. The home currently has two vacancies. One person is due to move into the home over the next few weeks. This individual had been visited by at least 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. The manager stated these were going to be reviewed to be User Friendly Format in early 08. These will be reviewed at the next inspection. The Copse DS0000020375.V352339.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning process has significantly improved. Systems are in place to enable people living at the home to contribute and participate in life at the home. EVIDENCE: Following requirements made at the February 2007 staff have continued to work hard in improving the care planning process. Four plans were viewed on this occasion. People living at the home 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.V352339.R01.S.doc Version 5.2 Page 11 Care plans give clear guidance to staff on the support needs of the individual. The plans are 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 person centred. The majority of people living at the home have reduce or no verbal communication. Since the last inspection staff have received training in the ability to communicate by other methods. This encourages 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. For example staff are currently working with one service user case tracked 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. These choice cards are also used for other individuals at the home. 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 ultimately allows the people living in the flats to express their opinions on the care and support provided and what improvements they would like to see. This allows all people the opportunity to participate in this way. It was pleasing to see there is 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 activities or social opportunities are available for that day. The Copse DS0000020375.V352339.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): 11, 12, 13, 14, 15, and 16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The opportunities for personal development and activities continue to improve with people living at the home having increased access to the local community and leisure activities. People living at the home have their rights respected with the increased communication systems. The home provides a healthy diet. It cannot be confirmed if active choices are available to all people living at the home. EVIDENCE: The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 13 The Copse is supported by Brandon day care to ensure that people living at the home are able to access the community and work closely with them to provide individual programmes, over and above the 9 – 4pm service which was provided. People are encouraged and supported to take part in daily living activities and to participate in flat meetings. There is an activities coordinator who assists in developing and running both group and individual sessions within the home. This ensures all people living at The Copse and staff interact throughout all aspects of their daily living and foster good working relationships. One comment made from the CSCI surveys include: ‘ Everyone at the Copse make it possible for my relative to have a happy, safe fulfilled life. Its like one big family there’. There is an increase in social and recreational opportunities within the home. A therapy room is enjoyed by a number of people living at The Copse. This is also 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, two of the ladies were seen enjoying completing Christmas decorating and some people were enjoying the sensory area. Interactions between staff and people living at the home were positive and appropriate. The meal on the day of the inspection was seen. The menu held in the office stated that two choices were available. The development of photographs is still being completed. However, there was displays of menus available on the day of inspection. 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 since the last inspection. There continues to be 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 continue to be supported to go out for meals to pubs and restaurants. Some pictorial menus have been undertaken and the manager stated that as menus are undertaken pictures of these are added to the portfolio. The Copse DS0000020375.V352339.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems for the administration, storage and documentation of medications 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. Evidence of individual input and families compiling support plans was observed in 3 of the 4 plans of care viewed. Discussions with staff also 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 and content on the day of the inspection. The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 15 People living at the home access health professionals such as GP or dentist in the community. This continues to help change the culture and reduce 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 in line with best practise guidelines. The management at the home now ensure that all staff that deal with medication, including agency staff, are aware of the procedures and disciplinary action is taken if these guidelines are not adhered to. Drug competency certificates were viewed for all who administer drugs. On the day of the inspection the Medication Administration Records were viewed. These were well maintained. Stock levels at the home were adequate. The drug fridge temperature was recorded and was within safe limits. The management conducts regular audits relating to medication. No people at the home are currently self-medicating. The Copse DS0000020375.V352339.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are dealt with appropriately. All staff continues to receive 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: Relatives meeting have increased. The last meeting was held in September 2007. This has enabled interested parties to raise concerns that they may have and also influence the running of the home. Communication methods have been reviewed and promote people living at the home to have the opportunity to express any concerns that they may have. Staff are aware of POVA and Whistle Blowing procedures and have undertaken training in this area. This was evidence by reviewing training matrix and gaining information on two scenarios put to two staff members. There responses were full and confident in manner. This suggests that people living, at The Copse are protected by suitable trained staff. Comments from survey returns include: The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 17 ‘We have no complaints’. Recruitment files for 3 staff members were reviewed and evidenced robust employment procedures. The complaints log was viewed and evidenced a complaints procedure. There were no new complaints since the last inspection date of February 2007. The Copse DS0000020375.V352339.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, 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 Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 19 The home is organised in to four “flats” two on the first floor and two on the ground floor. Each flat has it’s own entrance. This ensures that the privacy of people living in each of the flats 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. One person who has a large bed for their assessed needs has very limited space for staff to assist and undertakes using a standing frame to assist them in and out of the bed from their room. This has been assessed and the manager is undertaking funding to have a ceiling track. People who use a wheelchair can now access doors with openers fitted. The flat roof garden area has been re-laid in August 07 since the last inspection of February 07. 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 manager stated this was planned for early 08. The front door to the building has an automatic door. This door is now linked to the fire alarm system. A number of areas have been redecorated in flats of ‘Aspen’ and ‘Tamarind’ and the home has a rolling programme for decoration. One of the bathrooms has been fitted with a new bathing system. All areas of the home, including laundry were clean and tidy on the day of inspection. A Requirement was made in relation to these standards. The Copse DS0000020375.V352339.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): 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. 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 both had had a mentor. The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 21 Staff stated that training opportunities were available at the home and felt that this had contributed to the improvements made at the home. 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 • Smile no bullying • Dementia and challenging behaviour • Values and atieology of learning disability • Introduction to Epilepsy • Positive communication system • Advocacy 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 has been extended to all staff ensuring that effective communications methods are introduced and used apporopriatley 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 moving and handling, fire and recognision and prevention of abuse. Ancilalry staff have received training appropriate to their job role. Individual training files are at present being developed. 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”. Comment made from a survey return: ‘ There is always room for improvement. The Copse always try to do things to the best of their ability with the funds they are given. We have no complaints’. 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. 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 and evidence all staff receive a minimum of six supervisions annually. Staff also receive annual appraisals. Staff stated that they apprechated this support. The Copse DS0000020375.V352339.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, 38, 39, 40, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to improve since the last key inspection this is due to a strong management structure at the home. Evidence shows that service users views are beginning to underpin the development of the home through the new communication systems. These systems continue to be developed. The health, safety and welfare of people living at the home are promoted and protected. EVIDENCE: The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 23 During the inspection the manager completed an initial tour of the building with the inspector. During this time it was evident that Ms Noke continues to have a positive relationship with the people living at the home. Staff also confirmed that they continue to find 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 are encouraged by the improvements made and continue to develop the service. A series of meetings are now held including regular staff and relatives meetings. These enable all people to express their views. Minutes are then sent out to all relatives and advocates. One comment made in minutes of the 10/09/07 stated : ‘I would like to thank all at the Copse for the work undertaken here’. 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. The service is currently undertaking the ‘Investors in people award’. 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. 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.V352339.R01.S.doc Version 5.2 Page 24 A range of maintenance records were viewed and these showed that on the whole the home is well maintained. The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 25 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 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 x The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1. YA25 23 (2) (n) The home should have an action plan to improve accessibility for known person relating to accessing their bedroom and bed. 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. (Partially met previously set for 04/06/07) 03/02/08 2. YA24 23 (2) (b) 04/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 27 No. 1 Refer to Standard YA17 Good Practice Recommendations Complete the pictorial menu planning to enable complete choices for all people living at The Copse. The Copse DS0000020375.V352339.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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.V352339.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!