Inspection on 18/01/06 for 17 Berryfield Road

This inspection was carried out on 18th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Berryfield Road 19/06/08

17 Berryfield Road 31/07/06

17 Berryfield Road 08/09/05

17 Berryfield Road 21/02/05

17 Berryfield Road 12/10/04

17 Berryfield Road 16/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Berryfield Road (17) 17 Berryfield Road Bradford On Avon Wiltshire BA15 1SU Lead Inspector Malcolm Kippax Unannounced Inspection 18th January 2006 1:45 Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Berryfield Road (17) Address 17 Berryfield Road Bradford On Avon Wiltshire BA15 1SU 01225 864397 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) Ordinary Life Project Association Bernadette Anne Saunders Care Home 4 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: 17 Berryfield Road is run by the Ordinary Life Project Association (OLPA). The home is a domestic style, semi-detached property in a residential area of Bradford on Avon. It is next door to another OLPA care home, which is at no. 19. There are some local facilities and a bus service nearby. The town centre offers a wider range of shops and amenities. The home has its own people carrier for trips out. Each service user has their own room on the first floor. There is a communal lounge with a dining area. The service users receive support and personal care from a permanent staff team and manager. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 1.45 pm and 5.15 pm. There were three service users living at the home. Two service users were met with when they returned home from their day activities. There were individual meetings with the home’s manager and with a member of staff. The communal areas of the home were seen. Records, including meeting minutes, assessments, fire log book, and staff records were looked at. This inspection focussed on a number of key standards that were not assessed at the previous inspection of the home. Since the last inspection, the Commission has been informed of the unexpected death of a service user. What the service does well: What has improved since the last inspection? What they could do better: Individual contracts have not yet been agreed with the service users’ placing authority. A new and hygienic floor covering is needed in the laundry area. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 6 Staff members have not yet achieved the level of qualification that is expected. There is no accredited programme of induction for staff who are new to working in a learning disability service. There is a lack of evidence in the home to confirm that service users are adequately protected by the organisation’s recruitment practices. There is a lack of quality assurance and action plans for improvement. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 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 the following standard(s): These standards were not looked at on this occasion. (Standards 1, 2, 3, 4 and 5 were inspected at the last inspection. These standards were met, other than standard 5, which was almost met). EVIDENCE: In connection with standard 5, the Commission has been informed of discussions about contracts that are continuing between OLPA and Wiltshire County Council. It is of concern that individual contracts for the service users have not yet been agreed between OLPA and the funding authority. The Commission has also raised this with Wiltshire County Council. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 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 the following standard(s): 7 Service users can make decisions about their lives, with the support of staff. (Standards 6, 8 and 9 were inspected and met at the last inspection). EVIDENCE: ‘Tenants’ meetings take place in the home, when service users can raise their own issues. The minutes show that that they are asked for their views about the home and what they would like to do. The manager said that the home’s system of ‘Shared Action Planning’ was also a way in which service users can make decisions about their lives. The system involves service users receiving support with achieving their personal goals. Examples of the service users’ shared action plans, including their personal goals, had been looked at during the previous inspection. Individually, service users also make decisions at review meetings, which are attended by a range of interested parties. The manager said that each service user has had a review meeting during the last year. During the inspection, service users returned home from their day activities and quickly settled into their own routines. One service user chose to help out Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 10 with preparing the evening meal. Both service users appeared to be treating the home as their own and were able to decide how to spend their time. There are some agreed restrictions in place concerning one service user. These involve the kitchen and are well documented. A ‘Last wishes’ form is included on the service user’s individual files. This contains some of the information that would be needed when arranging a funeral. The manager said that, when the time is right, it is also the intention to discuss this area further with service users. This will help ensure that a service user’s wishes and preferences are known in advance and recorded. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 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 the following standard(s): 13 Service users make use of local facilities and have regular contact with the wider community. (Standards 12, 15, 16 and 17 were inspected and met at the last inspection). EVIDENCE: Each service user went out on the day of the inspection and was engaged in different activities away from the home. Service users have a mix of home and community based activities during the week. 17 Berryfield Road is a domestic style house in a well established residential area. It fits in well with the neighbouring properties. Service users and staff talked about the local facilities that are available and used. There is a post office within walking distance. Service users visit the library and cafes in Bradford-on-Avon. One service user goes to a local church each week, supported by a staff member. A local swimming pool is used. Some of the service users’ regular activities are based in one of the nearby towns. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 12 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 the following standard(s): These standards were not inspected on this occasion. (Standards 18, 19 and 20 were inspected and met at the last inspection). EVIDENCE: The details of standard 21 were not inspected although there was discussion with the manager about the arrangements that had been made following the unexpected death of a service user since the last inspection. Service users have received support with the bereavement and the time following the death was handled with sensitivity and care. It was recommended at the last inspection that a statement on personal care is produced to include the organisations policy on gender and personal care and to provide details of any limitations and restrictions that may apply in the provision of personal care. The organisation has produced a statement that focuses on the need for anti-discriminatory practice. Although this is important, other factors are also relevant and may justify limiting, on the basis of gender, the involvement that staff have in intimate personal care. The manager said that service users have been asked individually if they would mind receiving personal care from a male carer. It is recommended that OLPA continue to look at developing a more comprehensive organisational policy that will reflect good practice and the range of factors that need to be taken into account. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 13 It was recommended at the last inspection that an appropriate outside professional, e.g. a pharmacist, contributes to the training that staff receive in medication procedures and drug usage. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 Service users have the opportunity to raise concerns. The manager is looking positively at how service users can receive the information they need about complaints. Staff members receive guidance and training, which helps to protect service users from abuse. EVIDENCE: One of the service users mentioned some people from OLPA who she could talk to if not happy with something. OLPA has produced a written complaints procedure, although not all service users would find this to be a suitable format. The complaints leaflet is included in the service user’s guides. The manager said that service users are reminded of the complaints procedure at tenants meetings and are asked if they have any concerns. The meeting minutes showed that service users do raise concerns and are asked if they like the home as it is. The manager said that work had also been started on producing a pictorial version of the complaints procedure. The OLPA policies and procedures file includes a brief statement about the protection of vulnerable adults from abuse. This refers staff to the Department of Health ‘No Secrets’ guidance and to the policy and procedure for the protection of vulnerable adults in Swindon and Wiltshire. OLPA provides ‘in-house’ training for staff in ‘Abuse Awareness’. The staff member met with confirmed that she had received this training. Details of this training were also recorded on staff members’ individual training records. The Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 15 staff member was familiar with the POVA procedure and said that she had her own copy of ‘No Secrets’. No referrals have been made under the vulnerable adults procedure during the last year. The manager said that she not attended a training course for managers. Staff members may also find that external training in adult protection, for example involving a local vulnerable adults unit, would be useful in addition to the in-house arrangements. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 30 The accommodation is kept clean and tidy, although the floor covering in the laundry area is not hygienic. (Standards 24 and 28 were inspected and met at the last inspection). EVIDENCE: The areas of the home seen during the inspection looked clean and well looked after. Service users are expected to take some responsibility for their own rooms. Support workers take the lead in the cleaning of the communal and domestic areas. There are rotas and job lists in place for particular cleaning tasks. One service user’s bedroom has been redecorated since the last inspection. This was one of her goals as part of ‘shared action planning’. The office/staff sleeping-in room was being decorated at the time of the inspection. The attached garage is used as a utility area with laundry facilities. The washing machine was standing on a piece of carpet that had become stained and was in an unhygienic condition. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Statutory training is provided through OLPA in-house activities. Service users will also benefit from some specialist training that is being undertaken. However there is a lack of an accredited programme of induction for new staff. There is a lack of evidence in the home to confirm that service users are adequately protected by the organisation’s recruitment practices. Staff members are working towards achieving the level of qualification that is expected. EVIDENCE: One member of staff of the staff team has achieved NVQ at level 2. She is now hoping to follow this with NVQ at level 3. Another member of staff is due to start NVQ at level 2. The manager said that the most recently appointed support worker has been confirmed in post after a successful probationary period. This included completing an OLPA induction programme. Learning Disability Award Framework accredited training is not being provided. This is recommended for staff who are new to working in a learning disability service and can be used to provide the underpinning knowledge for progress towards achieving NVQs. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 18 The recruitment record for the new member of staff included written references, proof of identity and application/interviewing forms. There was a C.R.B. certificate, which had been issued a few days after the staff member had started work. The was no record of a ‘POVA First’ check having been made. This is a check that must be completed before a staff member starts work in the home. The staff training records show that staff members participate in a range of courses as part of the OLPA programme of training. This focuses on the statutory areas of training. The manager said that she had attended a training workshop, ‘Death, Dying and Bereavement: Supporting People with a Learning Disability’. OLPA have had some input into the planning of this event. Two staff members are due to attend the same event when it is held again in February. The staff team have also received training in relation to the needs of one service user and are gaining knowledge about a particular syndrome. The manager said that she will also be attending a conference in connection with this, where examples of good practice can be shared. The involvement of staff in these types of specialist training event is very positive development. Further opportunities for developing the staff training programme in this way should be looked at. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home benefits from an experienced manager who is gaining relevant qualifications. Systems of quality assurance are not well established. Risk assessments and systems are in place which promote the health and safety of service users is promoted through risk assessments. EVIDENCE: Bernie Saunders has been the registered manager at 17 Berryfield Road for a number of years. Bernie Saunders has obtained the registered managers award and said that she is expecting to complete NVQ in care at level 4 by the end of February. A staff member said that she felt valued in her work and can make suggestions about the home during staff meetings. It was evident from conversation during the inspection that the management approach is appropriately focused Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 20 on the needs of the service users. There was a good rapport between service users, staff member and manager. There was no evidence in the home of an organisational approach to quality assurance that is in line with National Minimum Standards. There is an OLPA policy on quality assurance, which refers to a number of internal and external devices by which the service is monitored. However, the policy does not refer to how these devices will contribute to a cycle of planning-action-review, involving timescales and the production of an improvement report / action plan. The manager said that she was working on an annual development plan for the home. There is a well organised risk assessment file. This included completed assessments arranged in sections for ‘House- General’, ‘Clients – General’ and ‘Clients – Individual’. The list of assessments had been updated in January 2006. The minutes of staff meetings showed that health & safety is discussed on a regular basis. The C.O.S.H.H. folder had been discussed at a recent meeting and staff were asked if there were any health & safety concerns at the time. There is a policy on moving and handling. The home’s fire log book was up to date. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 21 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 X 2 X 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 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 2 X X 3 X Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 22 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. 1 2 Standard YA30 YA34 Regulation 23(2) 19(1) Requirement The laundry area must have a floor covering that is impermeable and easily cleaned. The Commission must be informed of the date on which the outcome of a POVA check was received in respect of the new member of staff. The Commission is supplied with a report of the most recent review re: quality assurance that has been carried out in accordance with Regulation 24 of the Care Homes Regulations 2001. Timescale for action 31/03/06 28/02/06 3 YA39 24 30/04/06 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 YA5 Good Practice Recommendations That the licence agreements are discussed and agreed with the service users placing authorities. The agreements should include all items that are listed under Standard 5.2 of the National Minimum Standards (outstanding from last DS0000028388.V279853.R01.S.doc Version 5.1 Page 23 Berryfield Road (17) 2 YA18 3 YA20 4 5 6 YA23 YA35 YA37 inspection). That OLPA develop a comprehensive organisational policy on gender and personal care, which will reflect good practice and the range of factors that need to be taken into account (outstanding from last inspection). That an appropriate outside professional, e.g. a pharmacist, contributes to the training that staff receive in medication procedures and drug usage (outstanding from last inspection). That the manager attends an external course in the protection of vulnerable adults procedure. That L.D.A.F. accredited training is provided for staff who are new to working in a learning disability service. That the registered manager is involved in the formal interviews for new members of staff. Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Berryfield Road (17) DS0000028388.V279853.R01.S.doc Version 5.1 Page 25 - 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!