Inspection on 07/04/05 for The Copse

This inspection was carried out on 7th April 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

The Copse 03/12/07

The Copse 20/02/07

The Copse 19/04/06

The Copse 03/10/05

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 Oldmixon Weston super Mare BS24 9EX Lead Inspector Nicola Hill Unannounced 7/4/5 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 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 Stationary 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 Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 3 SERVICE INFORMATION Name of service The Copse Address Beechmount Close, Oldmixon,Weston super Mare Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01934 811448 01934 811352 postmaster@shaw.co.uk Shaw Healthcare (Homes) Limited N/A Care Home 24 Category(ies) of Learning disability (24), Physical disability (14) registration, with number of places The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Up to 14 residents with a learning disability and a physical disability, in total and maximum of 24 residents. Date of last inspection 11/12/10/2004 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 Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector undertook this unannounced inspection with the deputy manager of the home Penny Bryant. The residents were observed during lunchtime being well supported by the staff team, and then after lunch being supported with appropriate activities. The residents made positive comments about the meal, and the staff also observed that the quality and presentation of meals had improved. One resident stated that he chose the afternoon video because he enjoyed looking at fish. There was development of the outdoor activity at the home with a sensory garden having been planted for residents’ use, and the purchase of wooden swings, which residents chose. The home has also planned several activities to promote a wider community presence such as a strawberry fair. Some of the residents at The Copse have limited verbal communication and therefore some of the comments in the report are from observation. The staff on duty during the inspection were very positive about the recent managerial changes and particularly the promotion of the rights and choices of the resident group. What the service does well: What has improved since the last inspection? The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 6 The following areas were noted as improved since the last inspection:• reporting regulation 37 incidents • the residents medication is correctly stored and administered • supervision and appraisal of all staff on a regular basis • home support workers were positive about the leadership and management development in the home • staff rotas indicate that the home always meet minimum staffing levels and often exceed the level • the quality and variety of meals served to the residents has improved • the frequency and quality of staff meetings • recruitment of a permanent staff team so that residents have continuity of support • reduction in reliance on agency staff to cover annual leave and sick leave What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 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 Standards Statutory Requirements Identified During the Inspection The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 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 standard(s) 1 and 5 There is clear information available about the service for potential service users,and verifiable admission procedures for potential service users. EVIDENCE: There have been no admissions since the last inspection so the evidence for this standard was obtained from existing residents. The individual care files for residents indicated that a pre-admission assessment has been undertaken which ensured that the home was able to meet identified need. The potential residents and carers are given the service user guide to use to enable them to make an informed choice about the home and the services it offers. Pre admission visits over a period of time are part of the admission process at the home. All individual care files have a written contract for the residents concerning their residence at the home . The introduction of user friendly information would enable potential residents to have a greater understanding of services offered at the home. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 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 standard(s) 6,7,8 & 9 The care plans need to be updated, and information held on residents reviewed so that it reflects their current situation. EVIDENCE: The resident group at The Copse have varying abilities to self advocate and express themselves using verbal communication. The care files are in the process of being reviewed and edited so that out of date material is archived, and the information presented in the care files is current. The inspector reviewed the care plans for residents in two of the four flats. It was noted that they were all reviewed on one flat (Aspen), and that changes in the level and type of support needed were clearly identified. The inspector was also able to case track the changes in the care plans, and any reassessments made. On the other flat (Fern) the quality of care files was variable, some had been reviewed the majority of them have not been reviewed. The daily records for the residents were concise and informative, and the inspector was able case track through the records to follow up any incident that had occurred. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 10 The home are also in the process of introducing person centred planning for all the residents to ensure that individual needs, choices and aspirations are recorded and acted on. The residents are activities are risk assessed, which ensure that they are able to access the community with appropriate support. The risk assessments and the person centred plan, which identifies individual aspirations, will be linked so that resident aspirations can be fulfilled. . The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 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 standard(s) 12,16 & 17 Residents have varied levels of support for activities outside the home. EVIDENCE: Some residents have external support provided by the Brandon Trust community day-care service, whilst others attended centre based day services. There are in-house activities planned to meet the needs of residents who do not access either of these other services. The person centred planning process will identify the goals and aspirations for the residents, and therefore allow planning to take place for staff to be available to support residents toward these goals. The food and menu offered to the residents was under review, and it is noted that significant improvement has been made in the planning of menus, so that a varied diet is offered to the residents. There are also choices are vegetarian meals for those who wish them. The individual flats continue to record what the residents are eating on a daily basis, and this was available for the inspector to read. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 12 The inspector also spent time with the chef talking about how he planned to consult with resident to ensure that all the food supplied to them is their choice and supplies in a way in which they enjoy it. The inspector was also able to see the lunchtime meal being served residents, and noted that the use of fresh vegetables had increased, and the meal was very colourful and provided a mixture of textures and taste for the residents. The residents were observed to enjoy the meal provided. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 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 standard(s) 19 & 20 Residents’ medication is stored and administered correctly. EVIDENCE: The home are in the process of introducing the new care plan format, which encompasses Lifestyle choices and will identify the way in which each resident prefers to receive personal care. All the resident access local health care services and are supported for specialist health care services by the community learning disability team. None of the residents at The Copse are able to administer and take control of their own medication. The medication system at home was reviewed and on this occasion found to be correct. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 14 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 standard(s) 22 & 23 Residents at the home have their views listened to, and complaints and concerns are acted upon appropriately. EVIDENCE: The organisation has a rigorous complaints procedure; two complaints have been received since the last inspection. Both of these complaints have been investigated appropriately and any necessary remedial action taken. All staff at the home has undertaken training to enable them to recognise abusive practice, and the action to take to report any concerns. There have been adult protection issues at the home, and the local procedures followed. As a result of these investigations two members of staff (no longer working for Shaw) will be referred to the POVA list for consideration of their inclusion on the list. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 15 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 standard(s) 24 & 30 The residents at The Copse live in a safe environment that is regularly maintained. EVIDENCE: A brief tour of the building did not indicate any areas where there were any health and safety risks to either the residents or staff team. The handyman has redecorated several of the bedrooms that were identified at the last inspection as in need of improvement. The home has adaptations and equipment suitable to meet the needs of the resident group, it was noted that the hoists were in good working order and had recently been tested. There are ancillary staff at home that maintain its cleanliness. The home was clean and free from any offensive odours; remedial work as identified at the last inspection had been undertaken. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32 & 36 A competent and qualified staff team supports the residents. EVIDENCE: Progress has been made in the recruitment and retaining of staff. The staff vacancies at home have fallen, the staffing rota indicated that minimum staffing levels were met. The improvement in team stability will benefit the residents, as they will have a settled and familiar staff team who are experienced in meeting their needs. All of the residents have an allocated key worker. Training for staff is available, and there is an expectation that staff will attend statutory training updates as required. Each individual member of staff has a copy of the General Social Care Council code of practice available to them on their personal files. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 &43 The temporary manager has successfully provided leadership for the staff at home, and provided a safe environment for the residents. EVIDENCE: The temporary manager, Sue Bennett, has continued to implement good practice at home in respect of the implementation of the new care planning formats for residents, staff training and recruitment, and providing a safe and stimulating environment for the residents. The temporary manager has also demonstrated leadership skills in the administration of the home, staff management i.e. regular staff meetings with good attendance and has the confidence of the staff team who wish her to continue on a permanent basis. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 18 There was evidence of financial control on behalf of residents, monies held on behalf of residents were checked and found to be correct. There was documentary evidence of regular supervision and appraisal of staff; this was confirmed by staff members as being a useful practice to promote self-development. Shaw has an external assessor for Quality Assurance, information from this assessment is used for business planning purposes. The implementation of health and safety at the home was reviewed in respect of fire safety. These are implemented and recorded appropriately. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 Score 2 3 3 3 Standard No 24 25 26 27 28 29 30 Version 1.10 Score 3 x x x x x 3 Page 19 The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX 10 LIFESTYLES x Score STAFFING Standard No 11 12 13 14 15 16 17 x 3 x x x 3 3 Standard No 31 32 33 34 35 36 Score 3 3 x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 3 The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 20 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 6 Regulation 15 Requirement The care plans need to be updated, and information held on residents reviewed so that it reflects their current situation Timescale for action 7/10/05 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. Refer to Standard 1 Good Practice Recommendations The introduction of user friendly information would enable potential residents to have a greater understanding of services offered at the home. The Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 21 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Copse Beechmount Close, Old Mixon, Weston Super Mare, North Somerset, BS24 9EX Version 1.10 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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