Care Home: Copperbeech Care Home

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What the care home does well This home is bright, well furnished and maintained and provides its residents with a warm comfortable homely place to live. The manager has been in post for nearly eight months and has the knowledge and skills to ensure that residents receive a high standard of care in their personal, physical, social and environmental needs. She is fully aware of legislation and is working hard towards providing an excellent quality of service in the home. The quality of activities offered in the home is excellent, and in keeping with the assessed needs of the residents. Residents are able to choose if they wish to participate in activities, and any resident not participating will receive one to one social time with the activity co-ordinator or key worker on a daily basis.Copper Beech Care HomeDS0000067146.V375927.R01.S.docVersion 5.2 What has improved since the last inspection? A new format for pre-admission assessments has been produced, that has resulted in detailed information being obtained so that the manager may assess if the home has the facilities and staff have the skills and knowledge to meet the resident needs. Information obtained prior to a new resident being admitted to the home is used as the basis for care planning. There is a new care planning process that is available in computerised form and in written format, with clear guidelines for staff as to how they can meet residents assessed needs, without placing residents at risk. Care plans are regularly reviewed with any changes recorded and risk assessed. The receipt, recording, storage, administration and return of medicines used in the home is now well managed and does not place residents at risk. At present an extension is in the process of being completed, and there is a planned programme to totally refurbish the existing home. Since the last key inspection the carpeting on the ground floor corridor and stair case has been renewed, to ensure residents are not placed at risk of tripping and falling. Bedrooms, en-suites and communal toilets and bathrooms now have an accessible call bell for residents to use. An independent occupational health assessment has been carried out resulting in some aids being re-sited to enable ease of use for frail elderly residents. The standard of cleanliness, hygiene and infection control has improved and the home is free of offensive odours. The manager has carried out infection control monitoring which showed a high standard of compliance. All staff have either achieved NVQ level 2 or above or are working towards this qualification. All staff with exception of newly recruited staff have received health and safety related training. Many of the care staff have completed the National Further Certificate in Dementia Awareness and other work related training.Copper Beech Care HomeDS0000067146.V375927.R01.S.docVersion 5.2Recruitment procedures are robust ensuring that all new staff are appropriately vetted prior to being deployed to work in the home. Independent Health and Safety and Fire Risk assessments have been obtained and any issues have been or are in the process of being addressed. An independent Legionella risk assessment has been carried out, and will be reviewed annually. What the care home could do better: Minor improvements need to be made to care planning especially the recording of professional health care visits to ensure they are easily accessible. Where liquid medicines are used in the home these should be dated on day of opening for auditing purposes. The manager needs to produce an annual report relating to quality questionnaires and the quality monitoring of systems used in the home. Key inspection report CARE HOMES FOR OLDER PEOPLE Copper Beech Care Home 154 Barnhorn Road Little Common Bexhill-on-Sea East Sussex TN39 4QL Lead Inspector June Davies Key Unannounced Inspection 09:30 29th June 2009 DS0000067146.V375927.R01.S.do c Version 5.2 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 homes for older people 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. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 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 Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Copper Beech Care Home Address 154 Barnhorn Road Little Common Bexhill-on-Sea East Sussex TN39 4QL 01424 842770 01424 843154 copperbeechemi@btconnect.com 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) Meeraraj Limited Vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users should be aged sixty-five (65) years or over on admission. The maximum number of service users to be accommodated is twenty (20). Only service users with a dementia type illness to be accommodated. Date of last inspection 12th January 2009 Brief Description of the Service: Copper Beech Care Home is registered to provide personal care for up to 20 older people with a dementia type illness. It is situated in a residential area on the main road into Little Common, which is on the outskirts of Bexhill-on-Sea. At the present time an extension is being added to the home and the present home is also due to be refurbished this year. The home provides single accommodation on two floors, and residents are encouraged to personalise their own bedrooms with small pieces of furniture and ornaments. The communal space on the ground floor offers residents comfortable and attractive rooms, with the lounge/dining room large enough to be used for group activities. A shaft lift enables residents to have access to all parts of the building safely, and hoists are available if required for staff to assist residents. There is an attractive garden to the front that residents can use safely when weather permits. Parking for a number of cars is provided to the side and rear of the home. Up to date weekly fees can be obtained by contacting the appointed manager of the home. Items not covered by the fee are hairdressing, chiropody, toiletries, clothing, newspapers/magazines and other luxury items. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place on Monday 29th June 2009 over a period of 7 hours. During this time the inspector spoke with the manager, four members of staff, one visitor and four residents. Documentation relating to key standards inspected was viewed; observation took place of the environment. An audit was also carried out in relation to the management of medicines within the home. Residents were happy with the variety and standard of food produced in the home and said that the care they received was good and that staff were kind and considerate to them. A visitor said that they were happy with the care in the home; there had been a vast improvement in the laundry in the last six months. Staff spoken to were all enthusiastic about the improvements in the home, and the standard of care they provide to residents. What the service does well: This home is bright, well furnished and maintained and provides its residents with a warm comfortable homely place to live. The manager has been in post for nearly eight months and has the knowledge and skills to ensure that residents receive a high standard of care in their personal, physical, social and environmental needs. She is fully aware of legislation and is working hard towards providing an excellent quality of service in the home. The quality of activities offered in the home is excellent, and in keeping with the assessed needs of the residents. Residents are able to choose if they wish to participate in activities, and any resident not participating will receive one to one social time with the activity co-ordinator or key worker on a daily basis. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? A new format for pre-admission assessments has been produced, that has resulted in detailed information being obtained so that the manager may assess if the home has the facilities and staff have the skills and knowledge to meet the resident needs. Information obtained prior to a new resident being admitted to the home is used as the basis for care planning. There is a new care planning process that is available in computerised form and in written format, with clear guidelines for staff as to how they can meet residents assessed needs, without placing residents at risk. Care plans are regularly reviewed with any changes recorded and risk assessed. The receipt, recording, storage, administration and return of medicines used in the home is now well managed and does not place residents at risk. At present an extension is in the process of being completed, and there is a planned programme to totally refurbish the existing home. Since the last key inspection the carpeting on the ground floor corridor and stair case has been renewed, to ensure residents are not placed at risk of tripping and falling. Bedrooms, en-suites and communal toilets and bathrooms now have an accessible call bell for residents to use. An independent occupational health assessment has been carried out resulting in some aids being re-sited to enable ease of use for frail elderly residents. The standard of cleanliness, hygiene and infection control has improved and the home is free of offensive odours. The manager has carried out infection control monitoring which showed a high standard of compliance. All staff have either achieved NVQ level 2 or above or are working towards this qualification. All staff with exception of newly recruited staff have received health and safety related training. Many of the care staff have completed the National Further Certificate in Dementia Awareness and other work related training. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 7 Recruitment procedures are robust ensuring that all new staff are appropriately vetted prior to being deployed to work in the home. Independent Health and Safety and Fire Risk assessments have been obtained and any issues have been or are in the process of being addressed. An independent Legionella risk assessment has been carried out, and will be reviewed annually. What they could do better: 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. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 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): 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 homes statement of purpose and service user guide is good and provides prospective residents with the information they need to make a decision about moving into the home. Service users know that their personal and social needs are able to be met by the home. EVIDENCE: Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 10 The statement of purpose and service user guide has been updated to include details of the new extension, and the services that the home hopes to offer. This will enable prospective residents their relatives and or representatives to make an informed decision in regard to moving into the home. All prospective residents have a pre-admission assessment carried out by the manager prior to admission and where possible other information is gained from external health care professionals and relatives. These pre-admission assessments are used by the manager to ensure that the home has the facilities and that staff have the experience, skills and knowledge to meet the prospective residents assessed needs. Prospective residents and their relatives and or representatives are invited to visit the home prior to making their decision to move in so they may meet with the staff and other residents and view the rooms available to them. The home does not offer intermediate care. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 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): 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 care planning system is clear and with a few minor improvements will adequately provide staff with the information they need to satisfactorily meet residents’ needs. Personal care is offered in a way to protect residents’ privacy and dignity and promote independence. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure residents’ medication needs are met. EVIDENCE: Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 12 The home now has a computerised care planning package that is also produced in paper format. Care plans are initially based on pre-admission assessments and other information obtained prior to the resident moving into the home. There was no evidence to show that residents and or their relatives have been involved in drawing up this plan of care. Care plans showed detailed evidence of the how the residents needs were going to be met in relation to the residents personal, physical, and social care these had been risk assessed and gave staff clear guidelines as to how each aspect of care is going to be met while at the same time reducing any risks involved. Evidence was available to show that residents have access to a variety of health care professionals, although in some instances this information was not readily accessible. Care plans do have a professional visits form that had been used and in other instances professional health care visits had been recorded in the daily reports. Where bed rails are being used there is a health care professional assessment together with home risk assessment. The residents nutritional needs are assessed monthly and recorded any concerns are reported directly to the resident’s general practitioner. The home has changed its pharmacy supplier since the last key inspection. From viewing records, policies and procedures the inspector found that all the requirements made at the last key inspection and pharmacy random compliance visit had been met. Medicines in the home are now well managed and residents are not placed at risk. Policies and procedures have been reviewed and updated and include a PRN (as required) policy and procedure, together with individual risk assessments for each resident who has been prescribed PRN (as required) medication. Both the clinical room, controlled drugs cupboard and medicines trolley were seen to be clean and hygienic. All medicines are kept safely and medication administration records had no gaps. Any medicine not used is recorded and returned to the pharmacy in a timely manner. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 13 Throughout the inspection the inspector observed staff respecting the privacy and dignity of residents, when carrying out personal hygiene needs and when helping residents to feed. Staff were observed speaking to residents in a friendly and professional manner. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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): 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. Residents are able to make choices in regard to daily routines and the activities they wish to participate in. The home has an open visiting policy so that residents may see visitors at any time. Dietary needs of the residents are well catered for with a balanced and varied selection of fresh food available that meets with residents’ tastes and choices. EVIDENCE: Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 15 Residents are given the opportunity to make choice in regard to routines in the daily lives and this was evident on the day of the inspection, with residents being able to get up in the morning and rest in the afternoon. The home employs an activities co-ordinator, who has achieved an excellent activities programme for residents who have a dementia type illness. There are a variety of appropriate activities on offer to residents throughout the week. Residents who do not wish to participate in these organised activities receive one to one time with the activities co-ordinator or from their key worker on a daily basis. Staff and relatives take residents out into the community on a regular basis, to local shops, nearby towns, or for a walk along the sea front. There are a variety of outside entertainers who visit the home to provide entertainment for the residents. The residents particularly enjoy Pat a dog and cuddly bunnies coming into the home. At the present time none of the residents wish to participate in religious services, but the activities co-ordinator and manager said that should a resident wish to follow their religious beliefs, arrangements would be made for this to happen. The home has an open visiting policy and relatives and friends are made welcome by the staff at all times. Residents are able to bring in small items from their own homes when coming to stay at Copper Beech; this was evidenced from visiting four residents’ bedrooms. None of the residents in the home are able to manage their own financial affairs and have made arrangements with their relatives or representatives to do this on their behalf. Meals offered in the home are of a good quality, providing residents with a varied, appealing and nutritious diet. There are four weeks of menus, and these are rotated in order. The inspector took a lunch time meal with residents and found residents were very happy with the food that was provided to them. At the present time the home does not cater for specialised diets or liquidised foods, but are able to produce specialised foods as and when required. From observation it was found that staff ensure that there is a relaxed atmosphere, so that residents are able to eat at their leisure, and where residents require assistance with eating this is carried out discreetly. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 16 Staff were observed talking to residents in a kind and gentle manner. The manager is in the process of producing menus in picture format that residents can more easily relate to. The manager reported that picture menus have been a success, and that they will continue with this until all meals on the menu are included in this format. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 has a satisfactory complaints system with evidence that residents, their visitors and friends’ views are listened to and acted on. Staff have a good knowledge and understanding of Safeguarding Vulnerable Adults protection issues which helps to protect residents from abuse. EVIDENCE: The complaints policy and procedure has been reviewed and updated and is displayed within the home. Complaints forms are freely available to residents and people visiting the home and are obtained from a transparent plastic pocket on the notice board, next to the complaints policy and procedure. The home has received one complaint since the last inspection and this was seen to have been appropriately managed with feed back being given to the complainant. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 18 The Safeguarding Vulnerable Adults, Whistle blowing and Accepting Gifts policies and procedures have all been reviewed recently. Staff are made aware of these policies and procedures during initial induction into the working practices of the home and address them again during Skills for Care Induction. One Safeguarding Referral has been made to the Safeguarding team of East Sussex County Council Older Peoples Mental Health Team since the last inspection. This was in regard to physical abuse resident to resident. The referral was made by the manager and has been properly investigated and is now closed. All staff working in the home have received Safeguarding Vulnerable Adults training. All staff are appropriately vetted prior to taking up employment in the home to help prevent residents being put at risk from abuse. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 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): 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. Recent investment will considerably improve the appearance of this home creating a comfortable and safe environment for those living there and visiting. Infection control procedures are well managed helping to ensure that residents are not placed at risk from cross infection. EVIDENCE: Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 20 At the present time Copper Beech is in the process of major extension work taking place which should be finished within the next six to eight weeks. Application has been made to the commission for variation of registration. Discussion has taken place with residents and relatives, so that residents can move into the new build while extensive refurbishment takes place in the existing home. At the present time the home is comfortable, light and airy and provides residents with a pleasant environment in which to live. All furniture and soft furnishings are domestic in style. Resident’s bedrooms are well maintained, decorated and furnished and contain resident’s personal belongings to reflect their interests and personalities. Communal bathrooms and toilets are well maintained and hygienic. The home has had a recent Occupational Health Inspection, and some hand rails have been moved to ensure that residents have mobility aids at the correct height and place to assist them. The hall and stair carpet has been replaced and no longer poses a risk to residents. Residents do not have free access to the garden area due to the building works taking place, which may place residents at risk. Residents only go into the garden area when supervised by staff to reduce the risk of accidents. The manager stated that she called upon continence nurse to give staff guidance in regard to toileting routines, and this has helped to keep the home odour free. All communal toilets and bathrooms are supplied with liquid soap and paper handtowels. Clinical waste bins are placed in each communal bathroom. There was evidence in communal bathrooms that staff are supplied with disposable aprons and gloves to help prevent cross infection. The laundry is in immaculate condition. Red alginate bags are used for foul linen. Floors, walls and exposed pipe work are clean and free from dirt and dust. The floor is mopped down several times a day to ensure hygiene and cleanliness. There is good evidence that the laundress respects the resident’s Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 21 personal clothing and linen and ensures that is it laundered according to instructions. One visitor said how much the laundry had improved over the last six months. The manager has recently completed an infection control survey of the home and has scored a high percentage, and knows where improvements need to be made, to ensure 100 infection control procedures. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are 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): 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. With the present resident numbers and their assessed needs there are suitable numbers of staff on duty. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Staff are multi skilled and this helps ensure good quality of care and support. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. Since the last inspection the standard of recruitment practice has improved, with appropriate vetting of new staff taking place to help prevent residents being placed at risk of abuse. EVIDENCE: Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 23 At the present time there are 9 residents in the home that have been risk assessed as high needs. On the day of inspection there were sufficient staff on duty to meet with residents’ assessed choices and needs. The manager is aware that she needs to keep staffing levels under constant review to meet the changing needs of the residents. In total 17 staff are employed in the home excluding the manager. Sixty seven percent of care staff have achieved their NVQ level 2 or above in social care, with the remaining staff working toward their NVQ qualification. The Chef has just completed his Advance Food Hygiene Course and is about to embark on a City and Guilds Catering qualification. The Laundress has achieved a NVQ qualification in Hospitality and the housekeeper is in the process of doing a Level 2 NVQ in housekeeping. From staff personnel files viewed, there is good evidence that all prospective staff are appropriately checked prior to being deployed to work in the home. This helps to ensure that residents are not placed at risk of abuse. Staff mandatory and work related training is excellent, with exception of new members of staff all staff have undertaken mandatory training, with further courses being booked to ensure that all staff have been trained or have updated this training. This helps to ensure that staff are knowledgeable in health and safety procedures and residents are not placed at risk. Staff work very positively together and with residents, and there is a good staff atmosphere. Staff in conversation were positive about their work and showed that they had the skills, knowledge and experience to meet needs of residents with dementia type illnesses. All new staff are required to complete the initial induction into the home, and to follow this up with Skills for Care induction to ensure that they have the basic knowledge of how the home works and caring procedures. New staff are given the General Social Care Council Code of Conduct booklet. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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): 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 Manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The quality assurance system in the home is good ensuring that residents and/ or relatives, representatives and stakeholder views are sought, and the systems used in the home are closely monitored ensuring that residents receive a good quality of care throughout. Health and safety within the home is rigorously monitored to ensure that residents’ live and staff work in a safe environment with minimal risk to their well being. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager, Shelley Rabbit has been in post for 9 months, her application to be registered with CQC is being processed and she is awaiting her registered manager’s interview. She has the skills, qualifications and experience to manager the home being a registered level 2 Mental Health Nurse, has NVQ level 4, Leadership and Management at Level 3, D32 and D33 assessors’ award. Shelley has updated her mandatory training alongside the staff team. She has a train the trainers award and is about to update her knowledge on the Mental Capacity Act and Deprivation of Liberty. Shelley Rabbit has done an excellent job since the last inspection in ensuring that all the requirements made at that inspection have been met, and in lifting the staff atmosphere in the home, so that residents receive care from a professional, skilled, knowledgeable and happy staff team. The manager is well supported by the registered provider, who together ensure that they work towards providing a good standard of quality care. The manager has produced a new questionnaire format for checking the Quality of care in the home that has been sent out to relatives and stakeholders. Fifteen questionnaires were sent out, but only a few were received back, but all with positive comments. The manager regularly carries out monitoring of systems used in the home, all accidents and incident forms are monitored and where any one resident is experiencing a high level of falls, this is referred immediately to falls assessments team and general practitioner. Environmental risk assessments have been carried out in regard to health and safety and fire, by an independent body. The maintenance person regularly monitors health and safety and fire risks for each room in the home. The registered provider employs a consultant to carry out monthly regulation 26 visits to the home, and detailed reports are then drawn up following this visit. The home has an annual development plan that highlights areas in need of improvement. The manager is in the process of developing a quality assurance report that will incorporate findings from questionnaires and monitoring surveys, this will then be incorporated into next years development plan. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 26 The manager has no involvement in residents’ personal allowances. If purchase/s are made on a resident’s behalf, receipt/s are retained, the expenditure is then charged to relatives or representatives by invoice at the end of the month. All staff receive six formal supervisions per year, with evidence available on staff files of supervision taking place. Health and safety within the home is of prime importance. Nearly all staff have undertaken mandatory training, with further courses being booked to ensure that all staff have received or updated their training. All equipment and appliances used in the home has an up to date maintenance certificate. An independent Legionella check has been carried out this year. Records are available to show weekly checks take place in regard to fire points and hot water delivery. All accidents and incidents are recorded and these are monitored by manager, resident risk assessments are updated if need be, and multiple falls are reported to falls clinic and general practitioner, with evidence of this on residents care plan. Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 28 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. Refer to Standard Good Practice Recommendations Copper Beech Care Home DS0000067146.V375927.R01.S.doc Version 5.2 Page 29 Care Quality Commission South East The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiriessoutheast@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. 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