Care Home: Copperbeech

Similar services:

• Polesworth Group Friary Road
• Polesworth Group Pooley Heights
• Polesworth Group 32 Station Road
• Polesworth Group 70 Long Street
• Breme
• Polesworth Group 64 Long Street
• Polesworth Group 68 Long Street
• 10 Whitfield Avenue

What the care home does well There are a wide range of activities that people are supported to do to ensure that they do the things they like.CopperbeechDS0000016887.V377601.R01.S.docVersion 5.3People are able to choose their own meals so that they have food that they like to eat. People who live at the home have access to a range of Health and Social care professionals and this ensures that any healthcare needs are met. The management of medication is good and ensures that people receive their medication as prescribed. The home creates a friendly and welcoming atmosphere where people can personalize their rooms to reflect individual preferences and tastes. Meetings are held so that people are given the opportunity to discuss things they would like to do. Staff receive training to ensure that they have the knowledge and skills to meet people`s needs. Staff assist people in a calm and respectful manner and know how to support them to meet their needs. There are robust maintenance checks on equipment to ensure that it is in safe and in full working order. What has improved since the last inspection? The recording systems and structures had all been reviewed. Old documents had been archived so it was easier to get the information needed from the records we looked at. Care plans have been re written and provide staff with good details about how people need to be supported to meet their needs. A number of improvements have been made to the environment including new furniture and redecoration. This enhances the environment for people to live in. Records regarding people`s personal monies are easy to audit and tell people what they have to pay for. What the care home could do better: Information about the home should be available in a format that people who live at the home can understand. The outcome of complaints and actions taken should be recorded so that people know that they have been listened to.CopperbeechDS0000016887.V377601.R01.S.doc Version 5.3 A training matrix should be devised to show what training staff have had and to assist with planning of training needs. Staff meetings should be held frequently so that staff can discuss ideas and concerns about the home. Staff should receive supervision at least six times per year to ensure that they are competent in their roles. All staff should take part in two fire drills per year to ensure that they know what to do if there was a fire so that they can protect people from harm. Key inspection report CARE HOME ADULTS 18-65 Copperbeech 23 Copperbeech Drive Balsall Heath Birmingham West Midlands B12 8SN Lead Inspector Lisa Evitts Key Unannounced Inspection 17th September 2009 09:40 Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Copperbeech Address 23 Copperbeech Drive Balsall Heath Birmingham West Midlands B12 8SN 0121 440 8419 0121 440 8419 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) Milbury Care Services Ltd Miss Kim Jacqueline Powell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) 4 The maximum number of service users who can be accommodated is: 4 8th August 2008 Date of last inspection Brief Description of the Service: 23 Copperbeech Drive is registered to provide accommodation, care and support for four adults with learning disabilities. The Home is run by Milbury Care Services. The property is a two-storey house in a residential development in the Balsall Heath area of Birmingham. There are four single bedrooms, one of which is on the ground floor. Downstairs there is a domestic style kitchen, separate laundry, lounge, conservatory dining room and an assisted bathroom and toilet. Upstairs are three bedrooms, a domestic style bathroom and toilet. There is also a small office. To the rear of the house is a secure small garden, and there is a paved area at the front of the property with limited off-road parking. There is a range of shops and community facilities close by, and the area is well served by public transport. At the time of our visit the service user guide states the fee level for living at the home as £989.79 per week. Additional charges apply for some transport, meals and activities. Previous inspection reports and articles of interest are available inside the hallway area of the home, for anyone who wishes to read them. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This visit to the home was undertaken by one inspector over one day. The home did not know that We, the commission were visiting that day. There were four people living at the home. It was not possible to gain direct comments from the people living in the home due to their communication needs. Information was gathered from observing people who live at the home and from speaking to three staff. Two people were case tracked. Case tracking involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. Prior to the inspection we sent out random surveys in order to gain peoples views about the service. We sent four surveys to people who live in the home and their relatives and five to staff. Three people who live at the home, four members of staff and two advocates returned surveys. Comments are included in this report. We were sent an Annual Quality Assurance Assessment (AQAA) by the home. This tells us about what the home think they are doing well and where they need to improve. It also gives us some numerical information about the staff and people who live at the home. Before the visit we reviewed any information we had received about the home since our last visit. What the service does well: There are a wide range of activities that people are supported to do to ensure that they do the things they like. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 6 People are able to choose their own meals so that they have food that they like to eat. People who live at the home have access to a range of Health and Social care professionals and this ensures that any healthcare needs are met. The management of medication is good and ensures that people receive their medication as prescribed. The home creates a friendly and welcoming atmosphere where people can personalize their rooms to reflect individual preferences and tastes. Meetings are held so that people are given the opportunity to discuss things they would like to do. Staff receive training to ensure that they have the knowledge and skills to meet peoples needs. Staff assist people in a calm and respectful manner and know how to support them to meet their needs. There are robust maintenance checks on equipment to ensure that it is in safe and in full working order. What has improved since the last inspection? What they could do better: Information about the home should be available in a format that people who live at the home can understand. The outcome of complaints and actions taken should be recorded so that people know that they have been listened to. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 7 A training matrix should be devised to show what training staff have had and to assist with planning of training needs. Staff meetings should be held frequently so that staff can discuss ideas and concerns about the home. Staff should receive supervision at least six times per year to ensure that they are competent in their roles. All staff should take part in two fire drills per year to ensure that they know what to do if there was a fire so that they can protect people from harm. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 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 Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have information to enable them to make an informed decision about whether they would like to live at the home. EVIDENCE: The statement of purpose and the service user guide was available in the hallway area of the home, and on each persons file. The documents contained all the information people would need to know about the home. They were written in a standard format. The AQAA stated that the home planned to develop these documents so that individual people would be able to understand the information more easily. The certificate of registration is displayed so that people can see this when visiting and a copy of the last inspection report is available for people to read if they want to. There had not been any new admissions into the home and the people who live at the home have done so for a number of years. We discussed the process of admission with the acting manager. They told us that this would include assessments and the opportunity to visit the home, sample a meal and even Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 10 stay overnight so that the person could see what it would be like to live there. They would also take into consideration the needs of the people who already live at the home and this should mean that the prospective resident and the home know that their needs can be met if they decide to move in. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have the information they need so they know how to support people safely to meet their needs and make choices about their day-to-day lives. EVIDENCE: The acting manager had reviewed peoples needs and re written three of the four care files to ensure that staff had current information about how to meet peoples needs. One member of staff said Care plans are better and its easier to understand what we are doing. This should mean that people are supported to meet their needs in a way that they prefer. Each person had a written care plan. This is an individualised plan about what support is required from staff in order for the person to meet their needs. We looked at two peoples care files. These stated how staff are to support the person with their personal care, leisure and social needs, sleep, eating and Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 12 drinking and health needs. The plans also stated what peoples likes and dislikes were. The plans also included details about how staff could help people to maintain their independence. Staff spoken to were able to tell us about peoples needs and this reflected the information that was in the care plans. Staff were observed to talk to people and spend time with individuals. It was clear that people in the home had built up good relationships with the staff. During the day we observed people being given choices about going out of the home and what food and drinks they preferred. People moved around the home as they chose to and one person had chosen to have a lie in on the day of our visit. In the surveys returned to us by the people living at the home, people told us that they could do what they wanted to at all times of the day. Records included risk assessments for individual needs. These detailed what staff needed to do to assist the person to be independent whilst keeping them safe. For example one person liked to go swimming and a risk assessment was in place to support them to be able to do this activity. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: 12,13,14,15,16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living there experience a meaningful lifestyle. They are offered a varied diet of their choice so ensuring their well being. EVIDENCE: Sampling of records and observations show that people who live at the home have opportunities to participate in a wide variety of activities. On the day of our visit one person was supported to go to an appointment in a taxi with a member of staff. One person went out with a member of staff shopping and then for lunch. In the afternoon two people went into town with a carer shopping. People have the opportunity to take part in activities at the home and in the local community. Two people who live at the home go to college for two full Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 14 days a week to study courses of interest to them such as gardening. There was evidence in peoples files and from receipts of money spent, of people going to the cinema, bowling, swimming and out for meals. There were also receipts for aromatherapy, toiletries and personal likes such as lager, sweets and magazines. One person had been on an adventure holiday earlier in the year and one person was looking into a holiday with their key worker. This means that people do the things that they enjoy. Records indicated that people were encouraged to use their skills around the home and helped with laundry and domestic duties such as tidying rooms. Each Sunday a residents meeting is held and records showed that staff discussed with people what activities they would like to do the following week and what meals they would like. One person had been looking forward to a new bed being delivered and we saw that this had now arrived. The home has an open visiting policy and people are supported to maintain contact with family and friends. Some people have visitors and some people go and stay with their relatives on occasions throughout the year. One person maintains contact with a relative through phone calls and letters. This means that people maintain relationships that are important to them. People living at the home receive a choice of meals which are decided with the people who live there each week. People have two choices at breakfast, lunch and dinner. Menus showed meals such as shepherds pie and vegetables, spaghetti on toast, fish and chips and beef and potatoes. People also go out for meals and sometimes have a take away. One person has a menu board in the kitchen. This has a variety of laminated pictures so they can choose their meals each day and they can look to see what they have chosen. This means that people should receive the meals that they like. People were seen to have snacks such as crisps and biscuits during the day and were supported to make drinks where they were able to do this themselves. Records of meals taken were kept for each person so that staff could monitor individuals dietary intake. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal care and health needs of the people living there are met to ensure their well being. EVIDENCE: The new care plans that had been written included good details about how staff should support people to ensure that their personal and healthcare needs are met and in a way that they prefer. Examples of this are I like to have a shower around 8pm and then I like to come back downstairs to make myself a drink and snack and Staff need to remind me to clean my ears. The plans told staff what people could do to maintain independence and identified what staff needed to do to support people. There were detailed plans written for health concerns such as hay fever, constipation and depression. These gave details of how the person may be affected, any medication they may need and the support required from staff. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 16 Health records indicated that people are receiving access to dentists, opticians and general practitioners. They are supported to attend appointments at the GP surgery and at the hospital. There were no records for chiropody and the acting manager was reviewing this to ensure that people received this care as they needed it. During our visit we saw that people had been supported to dress in clothes that were suitable for their age and gender and reflected personal choices. One person had been assisted by staff to wear make up. We looked at the management of medication. Each person had a photograph so that staff could identify the person safely. There was information about how people liked to take their medication so that they received it in a way they preferred. All of the audits were correct and the charts were all signed when the medication had been given. There were no Controlled drugs at the home and no medications that needed to be stored in a fridge. Copies of prescriptions were kept so that staff could check that they had received the correct medication into the home. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples views are listened to and acted on. Systems should ensure people are safeguarded from harm. EVIDENCE: The complaints procedure is displayed in the hallway of the home and is included in the service user guide. In addition the AQAA told us that people at the home are provided with an accessible complaints procedure called letting us know what you think. In the surveys we received from people who live at the home, people told us that they knew how to make a complaint if they were unhappy. We have not received any complaints or concerns about this home since the last inspection. The home had received one complaint since our last visit regarding staff quarrelling. The outcome of this had not been recorded in the complaints log. The acting manager was able to give a verbal account of the outcome and actions taken and sent us further information following our visit to support this. Actions taken and the outcome should be recorded in the complaints record so that people know they have been listened to. The home had an adult protection policy and local multi agency guidelines for staff to refer to. Staff receive training in safeguarding people. Staff spoken to gave a good account of the action they would take in the event of an allegation Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 18 being made. This should mean that people are protected from harm. There have not been any adult protection cases opened at the home since our last visit. Staff had received training in the Mental Capacity Act. The acting manager had received training in the Deprivation of Liberty Safeguarding. This act governs decision making on behalf of adults and applies when people lose mental capacity at some point in their lives or when they have had an incapacitating condition since birth. This training was to be rolled out to other staff so that they have the knowledge about the procedure to follow when peoples freedom may be restricted. The acting manager had contacted an advocacy service to advise that people who live in the home may require advocacy services in the future. This should ensure that people are supported to make their own decisions where they are able to. The home is able to hold small amounts of personal monies. Financial records were seen for two people who live at the home. Receipts were available for all money spent and individual balances were correct. The money is audited each month by an external manager, so that any discrepancies would be found and rectified. Improvements had been made to these records since our last visit as they were easy to audit and receipts cross referenced to the expenditure records. Records were clear about how much the home would contribute to meals and travelling expenses and what people living at the home would have to pay. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, clean and comfortable environment which meets their individual needs. EVIDENCE: We looked around the home at the areas relevant to the people who lived there. The home is a domestic style property which has four single bedrooms. There is a large kitchen, a lounge, a conservatory/dining room and a laundry room. On the ground floor there is an assisted bathroom and a domestic style bathroom on the first floor. During our visit the home was clean and free from odours, there was a pleasant atmosphere and people who live at the home were seen to move around the home as they chose. In the surveys returned to us people told us that the home was always clean and fresh. One person was observed lying on Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 20 the sofa with their feet up, watching TV and eating a packet of crisps. This showed that people feel at home. The AQAA told us that a new dining table and sofa had been purchased. The hallway and laundry had recently been re painted and these improvements enhance the environment in which people live. The home has a small garden area and the AQAA told us that the home plans to improve this area to make it more interesting for the people who live there. One person who lives at the home has enrolled onto a horticultural course at college and may become involved in improving the garden area. We looked at peoples bedrooms and found that they were personalised with items that reflected their individual preferences and choices. One person had had a new bed and their room was painted pink. Another person had just had some built in wardrobes and had chosen the colours for the room to be decorated. Another person was going out to buy some blinds for their room as they did not like curtains at the windows. This means that people have rooms that meet their individual preferences. The bedroom doors all had locks so that people could lock them if they chose to but no one wanted to do this. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by staff who receive training to ensure they have the knowledge to meet peoples needs. People are protected from harm by the recruitment procedure. EVIDENCE: The home has two support staff on duty throughout the day and one support worker at night. Staff are responsible for assisting people to keep the home clean, go food shopping and to do their laundry as well as assisting them with personal care. The home did not have any vacancies and has reduced it use of agency staff down to none, which means that people know who will be assisting them to meet their needs. In the surveys returned to us, people told us that staff treated them well and listened to them. Staff were observed to interact well with people who live at the home and there was a pleasant atmosphere. Staff encouraged people to maintain their independence and promoted social skills. For example, one Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 22 support worker had encouraged a person at the home to shake hands with people when he met them. 50 per cent of staff have a National Vocational Qualification (NVQ) in care. This means that staff should have the knowledge and skills to meet peoples needs, both individually and collectively. There had only been one person employed at the home since our last visit. We looked at their file and it contained all of the information required to ensure that people were safe from harm. Staff had individual training records and copies of certificates were kept on file. Staff had received training in adult protection, fire, Mental Capacity Act, first aid, medication awareness and moving and handling. The training matrix was not up to date and it was difficult to determine the numbers of staff who had received the training. The last minutes of a staff meeting were dated August 2008. The manager confirmed that no meetings had been held since she had been at the home. The manager told us that a meeting for staff had been held with the operations manager (a senior external manager) but there were no minutes written up from this as it had only taken place the week before. Staff meetings should be held so that staff can raise any concerns and discuss ideas to move the home forward. We looked at staff supervision records and only one member of staff had any supervision recorded this year. The manager confirmed that she had only supervised one member of staff and was aware that this is an area to be addressed. Staff should receive a minimum of six supervision sessions per year. This will ensure that they are performing well in their roles and identify any training needs, so that peoples needs are met. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in the best interests of the people who live there. EVIDENCE: The registered manager is currently on maternity leave. A manager from another home is overseeing the home and works at the home for three days a week. She is available by phone at other times and staff can contact her for advice at anytime. The manager has worked to address the issues we found at our last visit. There have been a number of improvements to documentation regarding finances and care plans. People who live at the home knew the manager by name and we observed that they all had a good relationship with her. One member of staff said she is approachable and the home runs a lot more smoothly now. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 24 An external manager of the organisation visits the home each month and writes a report on the quality of the service to ensure it is meeting the needs of the people who live there. The organisation complete an annual service review which details peoples views about the home, what it does well and how it can improve. Satisfaction surveys are sent out to relatives of people who live at the home, and anyone else involved in their care once a year. A meeting is held each week with the people who live at the home and this should ensure that people have a say about how their home is managed. Prior to the visit the acting manager returned the AQAA to us in the required timescale. Some areas of this were quite brief in parts and could have provided more information about the home and we discussed this with the acting manager on the day of the visit. The information that was provided was consistent with our findings. Records of servicing, tests and maintenance in respect of health and safety for utilities, equipment and appliances are well maintained and should ensure that they are safe to use. Fire equipment and the fire system are checked each week to ensure that they are in working order. Staff receive training in fire and staff spoken to were able to tell us what they would do in the event of a fire. A practise evacuation had been held at the home and the people who live there were involved. Fire drill records did not evidence that all staff had taken part in a fire drill and this was brought to the managers attention. One person who lives at the home has a hearing impairment and the home had purchased an alert system for them. In the event of the fire alarm being activated whilst the person was in their room, a light would flash and if in bed the pad would vibrate to alert them to the fire alarm. This should assist staff to protect people from harm. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Version 5.3 Page 26 Copperbeech DS0000016887.V377601.R01.S.doc Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA1 YA22 YA33 YA35 YA36 YA42 Good Practice Recommendations Information about the home should be available in a format that people who live at the home can understand easily. Outcomes of complaints and actions taken should be recorded so that people know that they have been listened to. A training matrix should be completed so that people know who has had training and what training needs there are. Staff meetings should be held frequently so that staff can discuss ideas and concerns about the home. Staff should receive supervision at least six times per year to ensure that they are competent in their roles. All staff should take part in fire drills per year to ensure that they know how to protect people in the event of a fire. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Copperbeech DS0000016887.V377601.R01.S.doc Version 5.3 Page 28 - 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!