Inspection on 19/06/08 for 17 Berryfield Road

This inspection was carried out on 19th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Berryfield Road 31/07/06

17 Berryfield Road 18/01/06

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 07/11/2008.

CARE HOME ADULTS 18-65 Berryfield Road (17) 17 Berryfield Road Bradford On Avon Wiltshire BA15 1SU Lead Inspector Elaine Barber Key Unannounced Inspection 19 June and 23rd July 2008 10:35a th Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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 (4) registration, with number of places Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2006 Brief Description of the Service: The home is run by the Ordinary Life Project Association (OLPA). 17 Berryfield Road 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 person has their own room on the first floor. There is a communal lounge with a dining area. The people who live at 17, Berryfield Road receive support and personal care from a permanent staff team that is managed by Bernie Saunders. The fees range from £686 per week. Inspection reports are available in the home and are also available on the CSCI website at: www.csci.org.uk. Berryfield Road (17) DS0000028388.V347820.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. We visited 17, Berryfield Road on 19th June 2008. The manager was on leave. The residential service co-ordinator was available during the morning of the inspection. We made another visit to the area office on 23rd July 2008. The manager sent us an Annual Quality Assurance Assessment (known as the AQAA). This was their own assessment of how they are performing. It also gave us some numerical information about the service. We met with four people who lived in the home. We met with the staff member on duty during the day, to obtain their views about the service. We also observed interactions between the staff members and the people who lived in the home. As part of the inspection process, we sent surveys to the care home for distribution to the people who lived there and their relatives. We received surveys back from three people who live at 17, Berryfield Road. We looked at various records and documents during the visit. These included care plans, risk assessments, health care and arrangements for managing medication, activities, complaints, staff recruitment and training. We looked at systems such as health and safety and quality assurance and also the accommodation. During the visit we assessed all key standards. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people who live in the home. What the service does well: There was a statement of purpose in words and pictures. Each person was given a service user guide with words and pictures which made it easier to understand. The statement of purpose and the service user guides contained all the required information about the service. People had good information about the service so that they would know what to expect from the service. People’s needs were assessed before they moved into the home so that their needs could be met. People could visit the home so that they could decide whether it was the right place for them. Each person had a license agreement and most people had a contract with social services and the home. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 6 Each person had a care plan and a person centred plan so that their needs, wishes and goals could be met and they felt well cared for. People made decisions about their lives and were supported to take risks as part of an independent lifestyle. People had activities that they enjoyed, including attending day services, college and the gym. They had opportunities to use community facilities such as the church, supermarkets, shops, cafés and garden centres. They kept in contact with their family and friends as they chose. They were involved in the routines and decision making in their home and they had a healthy diet and enjoyed their meals. People received personal care and support in ways they preferred to meet their needs. Each person was registered with a GP and saw other health care professionals as they needed. People’s physical and emotional health care needs were met. Staff supported people with their medication and people were protected by the systems for managing medication. People’s complaints were taken seriously and acted upon. There was a complaints procedure and people were given information about how to complain. There was also a protection from abuse policy and information about the local procedures. Staff had received training about prevention from abuse. People were protected from abuse, neglect and self harm. The home was an ordinary semi-detached house in keeping with other houses in the road. There was a large lounge and dining room and each person had their own bedroom, which was decorated and furnished according to their personal taste and wishes. The home was clean and tidy when we visited. People lived in a homely, comfortable, clean and safe environment suited to their needs. People were supported by staff who were supervised and trained to meet their needs. Staff had regular supervision with the manager. They also had all the required basic training and specialist training to meet the needs of the people whom they supported. The manager was appropriately qualified and experienced to manage the home. The necessary health and safety measures were in place. As a result people benefited from a well run home, where their safety and welfare were promoted. There was a quality assurance process. People were contributing to a review of quality in the home so that the home was run in their best interests. What has improved since the last inspection? Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 7 We made a recommendation at the last inspection that people’s spiritual needs and family contact should be described in their care plan. We noted that there was information about these in the plans to make sure that these needs were met. We also made a recommendation at the last inspection that OLPA should 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. We saw in the files that there was a policy and that each person had a record of whether they were agreeable to support from a member of staff of the opposite gender. The sitting room and dining room had been redecorated and people had been involved in choosing the colours. The bathroom and toilet had also been repainted. The quality assurance process had been developed further. Questionnaires were sent to people and their views were gathered. A development plan, based on their views and ideas about how the home could improve, had been written and was being acted upon. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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 Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 Quality in this outcome area is good. People had good information about the service so that they would know what to expect from the service. People’s needs were assessed before they moved into the home so that their needs could be met. People could visit the home so that they could decide whether it was the right place for them. Each person had a license agreement and most people had a contract with social services and the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the Statement of Purpose. This contained the required information. It contained words and pictures and was easy to read. A copy of the last inspection report was made available and there was also information about advocacy. We also looked at the service user guide. Each person had a copy of their own service user guide which contained a summary of the statement of purpose. There was also information about the service provided, a copy of the license agreement, information about key policies including complaints and prevention from abuse. These guides were in words and pictures and contained information about advocacy. Each person also had more specific information about the service that they received. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 10 There was information in the statement of purpose about the admissions procedure. The manager told us in the AQAA that prospective new tenants had visits to the home before they move in and new people are given the statement of purpose. Other people are consulted about the move in tenants’ meetings. One person had moved into the home since the last inspection. We looked at their file and we read that the admissions procedure had been followed. They had two visits to the home to meet the staff and other tenants before they decided to move in. There was a record of a discussion in the tenants’ meeting and everyone was happy with the person moving in. The person had a copy of their care management assessment in their file. Their social worker reviewed their placement six weeks after they moved in and then three months after that. The other three people had moved into the home before the last inspection and their needs had been assessed before they moved into the home. Each person had a copy of their license agreement in their service user guide. All except the new person also had a copy of their contract with the home and the local authority that paid for their care. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. Each person had a care plan and a person centred plan so that their needs, wishes and goals could be met and they felt well cared for. People made decisions about their lives and were supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the files of three people. Each person had a care plan, which described the support that they needed with daily living. Each person also had a person centred plan, which described the support that they needed with their life plan and long term goals. The care plans and person centred plans were reviewed every three months and the changes were recorded. Three people who completed surveys said that they felt well cared for. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 12 We saw records of personal planning meetings, which showed how people were involved in developing their plans and making decisions about their lives. Each person had information about advocacy in their service user guide. One person had a Mencap visitor. We saw minutes of tenants’ meetings in each person’s file. These minutes showed how they made decisions together and individually about the household, holiday and outings. Three people who completed surveys said that they were involved in making decisions in their home. Each person had a series of risk assessments. These included the action needed to reduce risks to the person, however, they did not include the benefits to the person of taking the risk. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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): 12. 13, 15, 16, 17 Quality in this outcome area is good. People had activities that they enjoyed. They had opportunities to use community facilities. They kept in contact with their family and friends as they chose. They were involved in the routines and decision making in their home and they had a healthy diet and enjoyed their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the three people’s person centred plans and care plans. These recorded people’s individual activities and interests. The records showed that one person liked to go to church and was also involved in church activities ad events. The plans showed that two people went to a day service, one person went to the gym, a club and college and another person did not have structured day time activities. A member of staff told us that they tried to take this person out with one member of staff at least once a day. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 14 When we visited two people had been out to a day service. A member of staff told us that these two people went to the day service four days a week. Another person was waiting in for a healthcare appointment. They said that they wanted to go to a garden centre after the appointment and we saw a staff member offer them a choice of three garden centres to visit. The fourth person had been to the gym with staff support. They told us that they went to the gym twice a week. They also went to a club on Monday and Wednesday and to college. The daily records and care plans showed how people were involved in the routines of the home and household chores such as laying the table, clearing away and meal preparation. People also cleaned their own rooms and did their washing with varying levels of support. We saw from the records that people also used community facilities such as the gym, the supermarket and shops, cafes, the barbers and hairdressers, the church and college. At home people told us that they watched TV, did puzzles and word searches, drew, looked at magazines and looked at books. In their surveys people told us that there were good activities. Plans for holidays were recorded in the person centred plans. One person had been on holiday with a club they went to, one person had been on holiday to France and one had been to a caravan. One person did not want to go on holiday at this time. The records showed how people kept in contact with family and friends. A staff member told us that one person kept in contact with their parents and two people had contact with sisters and cousins. Staff had a record of the people another person wished to keep in contact with and those they did not wish to see. They had contact with some relatives and a friend. One person told us that they had recently made a new friend and staff were trying to arrange for them to meet up with their friend for coffee. We made a recommendation at the last inspection that people’s spiritual needs and family contact should be described in their care plan. We noted that there was information about these in the plans. A record was kept for each person of the meals they had eaten. One person had a special diet and advice about this was recorded in their care plan. There were records in the daily diaries of how people made choices of meals. The records showed that people were eating a variety of foods. A staff member told us that people went shopping with staff support and chose what they wanted to eat. The records showed that people chose to eat different meals. When we visited we saw that one person was offered a choice of sandwiches for lunch. Three people who completed surveys said that they liked the food. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. People received personal care and support in ways they preferred to meet their needs. People’s physical and emotional health care needs were met. People were protected by the systems for managing medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw that the care plans described how people liked to be supported. We made a recommendation at the last inspection that OLPA should 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. We saw in the files that there was a policy and that each person had a record of whether they were agreeable to support from a member of staff of the opposite gender. Records were kept of appointments with health care professionals. These showed that people had appointments with their GP’s, a psychiatrist, the dentist, optician, podiatrist, community nurse and dietician. A healthcare professional visited one person on the day of the inspection. No one else was Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 16 home and the staff made sure that they had sole use of the living room to see the professional in private. There was a record in each person’s file of any medication that they took and of any reviews by the GP or psychiatrist. There was also a record of each person’s capacity to consent to treatment. A record was kept of all medication ordered, received into the home, administered to people and returned to the pharmacy. Medication was stored in a locked cupboard. There were no controlled drugs. A member of staff said that staff had training about medication annually. The training records confirmed this. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. People’s complaints were taken seriously and acted upon. People were protected from abuse, neglect and self harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw that there was a complaints procedure with words and pictures. There was information about the complaints procedure and the protection of vulnerable adults procedure in each person’s service user guide. Each person had a stamped addressed postcard to the CSCI in their bedrooms, for them to use if they needed to. Everyone was asked in their monthly ‘tenant’ meetings if they were happy or had anything they would like to complain about. There was guidance in the home about adult protection, which was linked to the Wiltshire and Swindon ‘No Secrets guidance. The training records showed that all staff had received training about protection from abuse and two staff had had their training refreshed in June. One member of staff told us that they were due to have refresher training in September. At the last inspection we recommended that the manager attended an external adult protection training course. We saw no evidence that this had happened yet. Three people told us in their surveys that they felt safe in the home. There had been no complaints and no referrals to the adult protection team. There were additional policies and procedures on whistle blowing, bullying and harassment. There were also separate descriptions of how people received Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 18 support with managing their money. Records were kept of financial transactions when staff were helping people with their money. People sometimes signed the records when they had been given money. A staff member checked the financial records to ensure they corresponded with the amount in each person’s tin. A staff member told us that the records were regularly audited by a member of the office staff. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. People lived in a homely, comfortable, clean and safe environment suited to their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 17 Berryfield Road is in a quiet residential area in Bradford on Avon. The home fits in with the local environment. We looked at the accommodation. Staff told us that they had redecorated the sitting and dining rooms in the last year and people had been involved in choosing the colours and décor. There was a kitchen and a downstairs cloakroom. Staff also told us that there was a plan to refit the kitchen. The staff office and sleep in room were on the ground floor. On the first floor, there were four bedrooms; each person had their own bedroom, which also Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 20 had a hand washbasin. The bedrooms were individually decorated and reflected people’s tastes and interests. One person had their own key to their bedroom and was responsible for this. The bathroom and toilet had been redecorated since the last inspection. There was a large garden with a patio area that had garden furniture. The garden area had been improved since the last inspection and new plants had been added. The residential service co-ordinator described plans to add more plants to the rockery area. There was an outside rail by the front door and this had been replaced since the last inspection. The garage had been converted into a utility room. This provided suitable laundry facilities for the size of the home. The home was clean, tidy and smelled fresh on the day of inspection. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is adequate. People were supported by sufficient staff who were supervised and trained to meet their needs, but more staff needed to be qualified. People were not protected by the recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the rota. This showed that there were usually two staff on duty from 9 am until 5pm or 6pm. On Tuesday the second member of staff stayed until 8pm because one person went to a club. On Wednesday two staff were on duty until 9 pm because people went to another social club. One member of staff slept in at night. One member of staff had been recruited since the last inspection. They had left recently. The residential services co-ordinator told us that their recruitment checks were not kept in the home. They were kept at head office. When we telephoned head office a few days after the inspection, to arrange to see the records, we were told that the human resources manager, who looked Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 22 after these records, had just gone on leave and would not be back for two weeks. We were also told that no-one else had access to these records so that we could inspect them. We visited the office to inspect the recruitment records on 23rd July 2008. There was a recruitment checklist with some dates of when checks were received. The member of staff had filled in an application form. This contained a declaration that they had no convictions but they had not filled in that section. There were notes of their interview and a record of people’s feedback when they visited the house. The checklist stated that the member of staff started work on 1st October 2007. One written reference was received before this. One written reference, dated 4th October 2007, was received after they started. A Protection of Vulnerable Adults first check was received on 1st October 2007. There was no Criminal Records Bureau (CRB) check and no date on the checklist, or elsewhere, of when this was received. The human resources manager told us that there was a clear CRB check but she shredded it when the member of staff left. She also said that the member of staff worked for a fortnight shadowing other staff. She said that the CRB would have arrived before the member of staff started work or during the shadowing period. There was no written evidence to confirm this. The manager said in the AQAA that all the mandatory training was up to date. We looked at the training records of three members of staff. These showed that they had all received training in manual handling, fire safety, first aid, food hygiene, infection control, medication and abuse awareness. They also had more specialist training to support the needs of the people who lived at 17, Berryfield Road. We noted at the last inspection that new staff had learning disability award training as underpinning knowledge for National Vocational Qualifications (NVQ). The manager told us in the AQAA that there were five staff. Two had NVQ level 2 and three were working towards NVQ. We saw that there were supervision records in the staff files. These staff were receiving supervision every one to two months. A staff member told us that they had supervision bi-monthly and everyone had an annual appraisal. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. People benefited from a well run home, where their safety and welfare were promoted. People were contributing to a review of quality in the home so that the home was run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager had completed NVQ level 4 and had managed this service for over three years. They were away from the home for three and a half weeks at the time of the inspection. The manager was supported by other managers within the organisation including the Residential Service Coordinator who was present during the inspection. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 24 The organisation have some quality assurance policies and procedures, which describe the following: the Annual General Meeting, service users questionnaires, tenants meetings, managers and team meetings, Regulation 26 visits, external inspections and the cross referencing of standards. The organisation had devised a system for gathering the views of service users, relatives and stakeholders. Managers sent questionnaires to gather information about people’s views on the quality of the service. The form included a section for comments and for people to think about one thing the organisation could do better. We made a requirement at the last inspection that the Commission must be supplied with a copy of the report on the latest quality review. This had been addressed. A report of the findings of the 2006 questionnaires had been produced. Further questionnaires had been sent and a new development plan had been produced for 2008. This identified improvements such as redecorating the living room. The manager was involving one family in developing the kitchen. All the policies and procedures had been updated including the health and safety policy. We looked at the health and safety measures. There were individual and generic risk assessments. We saw that radiators in high risk areas such as the bathroom and toilet were covered. Others were behind furniture. The risk assessments showed that the temperature of the hot water was regulated at 43 degrees. A record was made in the personal file when someone needed help from staff to regulate the temperature of baths and showers. We looked at the maintenance log book which noted any maintenance issues and when they were fixed. We saw the fire log book which recorded when all the checks of the fire safety measures were made. We noted that all the appropriate checks were being carried out and staff were receiving fire instruction. There was information about Control of Substances Hazardous to Health (COSHH). Portable appliances were tested in April 2008. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 3 36 3 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 X 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 3 x Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 Requirement Timescale for action 19/06/08 2. YA34 17 (3) a Schedule 4 All the required recruitment checks, including a declaration about any convictions, two written references and a Criminal Records Bureau check, must be received before new staff start work. The recruitment records must at 19/06/08 all times be available for inspection so that we can establish whether people are at risk. 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. Refer to Standard YA9 YA20 Good Practice Recommendations The risk assessments could be improved by including information about why people are taking risks and how this benefits the person. A cupboard, which complies with the requirements for the storage of controlled drugs in care homes, should be obtained so that if people are prescribed controlled drugs they can be stored safely. DS0000028388.V347820.R01.S.doc Version 5.2 Page 27 Berryfield Road (17) 3. 4. YA23 YA23 5. YA37 6. YA37 7. YA37 That the manager should attend an external course in the protection of vulnerable adults procedure. When staff hand over a person’s money the person should sign the financial record to show that they have received it. When a person is not able to sign then two staff should sign the record. When staff recruitment records are kept in the head office a recruitment checklist should be kept in the home to show when all checks have been carried out and that people are being protected. (Information about arrangements for keeping records in a central office is available on the CSCI website: www.csci.org.uk.) Criminal Records Bureau (CRB) checks for staff should be kept until they have been inspected by an inspector from the Commission so that we can establish that people are being kept safe. When CRB checks are destroyed a record should be kept of the date the check was received, the serial number of the check and whether the check was satisfactory as proof that a check had been made. Berryfield Road (17) DS0000028388.V347820.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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