Inspection on 16/02/06 for 19 Berryfield Road

This inspection was carried out on 16th February 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

19 Berryfield Road 23/06/08

19 Berryfield Road 02/08/06

19 Berryfield Road 20/10/05

19 Berryfield Road 17/01/05

19 Berryfield Road 25/06/04

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 (19) 19 Berryfield Road Bradford on Avon Wiltshire BA15 1SU Lead Inspector Malcolm Kippax Announced Inspection 16th February 2006 10:00 Berryfield Road (19) DS0000028389.V283284.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 (19) DS0000028389.V283284.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 (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Berryfield Road (19) Address 19 Berryfield Road Bradford on Avon Wiltshire BA15 1SU 01225 868058 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 Ms Joanne Burrows Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 Brief Description of the Service: The home is run by the Ordinary Life Project Association (OLPA). 19 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. 17. There are some local facilities and a nearby bus route. 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. There is a large garden at the rear of the property. The service users receive support and personal care from the home’s manager and a permanent staff team. At least one member of staff is on duty when service users are in the home. Service users are supported with a range of community activities. Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was arranged at short notice at a time when the manager was working. It took place between 10 am and 3 pm. Two service users and a staff member were spoken with. Records were examined, including risk assessments, medication, healthcare, meeting minutes, health & safety and staff training. The communal rooms were seen. What the service does well: What has improved since the last inspection? What they could do better: The OLPA training plan is developing. The greater use of external trainers and courses would add a further dimension to the training that staff receive, in areas such as medication and the protection of vulnerable adults. The service users’ views are taken into account, although systems for quality assurance are not well developed. Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 6 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 (19) DS0000028389.V283284.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 (19) DS0000028389.V283284.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. No new service users have moved into the home during the last year. EVIDENCE: Berryfield Road (19) DS0000028389.V283284.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): 9 Service users are supported in being independent within their capabilities. (Standards 6 and 7 were met at the last inspection). EVIDENCE: Two service users were met with in the lounge and they spoke about their routines and activities. Service users were on holiday from their usual activities and had made other arrangements. One person was shortly to meet up with a friend and to take a taxi to a neighbouring town. She was looking forward to being able to do more journeys by bus and was practicing this with staff. The other service user said that she had recently visited a dogs’ home and was soon to start doing some voluntary work there. She said that a staff member will support her with this, but she was able to attend college independently. The manager said that another service user, who was not present at the time, needed staff support outside the home, other than for one well established daily outing. Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 10 A risk assessment file included assessments of some activities undertaken by service users in the community such as travelling by taxi. Other assessments were promoting independence within the home. These included a service user being able to prepare her own cooked meals. The risk assessment file was well organised and referenced. Berryfield Road (19) DS0000028389.V283284.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): These standards were not looked at on this occasion. (Standards 12, 13, 15, 16 and 17 were met at the last inspection). EVIDENCE: Berryfield Road (19) DS0000028389.V283284.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): 19 and 20 Service users receive good support with their healthcare and medication. (Standard 18 was met at the last inspection). EVIDENCE: There is an all-female staff team supporting the four female service users. The service users met with looked well supported with their personal appearance. The manager said that there were no concerns at the present time about the service users’ physical health. One service user has seen her GP and is waiting for an appointment with a specialist service for older people. All the service users are registered with GPs at the local health centre, which the manager and staff member said provided people with a good service. Reminders for healthcare appointments are recorded in the home’s diary. Details of the visits are made on separate forms, e.g. GP and Dentist, which are kept in the service users’ personal files. Two of the service users’ healthcare records were looked at. These showed recent appointments with the dentist and GP. Weight had last been checked in Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 13 January 2006. One service user has appointments with a chiropodist. Nail cutting by staff is recorded in the service users’ personal diaries. One service user had seen their GP in January 2006 for a drug review. The manager said that this person’s medication had reduced over time and that it was hoped that they would be able to come off it eventually, however the potential side effects are a consideration. A risk assessment may be useful in this situation. There are suitable facilities in place for the safekeeping of medication. Service users have signed consent forms for its administration by staff. There is a medication file, which includes drug information and daily recording charts. Records of administration were up to date. A relatively small error in the record of medication received in the home was identified but this could be easily accounted for. Staff members receive instruction in medication procedures through OLPA’s inhouse training programme. Berryfield Road (19) DS0000028389.V283284.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 are listened to. One service user is being well supported after making an external complaint. There is guidance and training for staff that helps to protect service users. Further training may be beneficial for some staff. A recent incident is being followed up. EVIDENCE: Service users have received information in their service user’s guide about how to make a complaint. The service users mentioned people outside the home who they could talk to if they wished. OLPA have produced a complaints leaflet. This does not meet each service user’s needs and the manager said that service users had also been given stamped addressed envelopes that they can to contact people outside the home. The ‘tenants’ meetings minutes showed that service users can raise concerns and discuss these with others. The manager reported on developments concerning a complaint that has been made by a service user against an outside agency. This has generated a lot of correspondence and the manager has spent time supporting the service with the process. The staff member met with had attended in-house training in abuse and P.O.V.A. during her period of induction. Other staff members have received this training, which the manager said happened once during their employment with OLPA. Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 15 OLPA have produced a brief policy on abuse, which refers staff to other documents. The manager reported on a recent incident that had arisen involving a service user. This has since been discussed with the service user’s placing authority, with a view to it being followed up under the protection of vulnerable adults procedure. The outcome of this was not known at the time of the inspection. The Commission was not originally notified of the incident. This was discussed with the manager, who is advised to contact the Commission if there is any uncertainty about whether a particular incident should be the subject of a notification. Berryfield Road (19) DS0000028389.V283284.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): These standards were not looked at on this occasion, other than to follow up some matters that were discussed at the previous inspection. (Standards 24, 26 and 28 were met at the last inspection. Standard 30 was almost met). EVIDENCE: At the last inspection, one service user said that she would like to be able to use a key when using her door lock on the outside, rather than having to use a coin in a slot, as under the present arrangement. It was recommended that the wishes of the service user are followed up and an appropriate door lock with a key is fitted to the bedroom door. In response to this, the inspector was told that this had been further discussed with the service user concerned and it was decided that the present arrangement would continue. There was a requirement at the last inspection that the three-piece suite in the lounge must receive attention or be replaced to ensure that it is clean and in good condition. The manager confirmed that it had been cleaned, but a new suite is shortly to be bought. The garage has been tidied up, although would benefit from some further storage facilities, which the manager said had been planned. The garden is being further developed with the installation of a new pond. Berryfield Road (19) DS0000028389.V283284.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 Staff members are working towards achieving relevant qualifications. The OLPA in-house training programme is being developed in areas that will be of benefit to service users, although there is a lack of accredited training for new staff. There was evidence of good recruitment practice, other than a lack of information that needs to be kept in the home about the completion of CRB and POVA checks for new staff. EVIDENCE: There is a staff team of four; two staff members were undertaking NVQ at level 3 and one person was shortly to start. One staff member had already achieved NVQ at level 2. An employment file had been set up for a member of staff who had started in the home since the last inspection This contained application and interviewing forms, references and other recruitment documentation. A ‘house visit’ feedback form had been completed, which included comments from the service users. There was no record of a C.R.B. disclosure check having been undertaken. The manager said that she had seen this and also been told that a POVA first check had been made, as the staff member had started before Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 18 their CRB disclosure had been received. There was no record of the POVA check or checklist of the recruitment documentation kept in the home. The new staff member did not have previous experience of working in a learning disability service. There is an OLPA induction programme, although Learning Disability Award Framework (LDAF) accredited training is not being provided. OLPA are therefore not achieving the standard for staff training and development. OLPA have previously been recommended to arrange LDAF accredited training, which will provide staff with the underpinning knowledge for progress towards achieving NVQ. The staff training records showed that following induction, staff members receive statutory training through OLPA’s in-house programme. A new skills training programme has been produced for 2006. The manager said that staff had been given new responsibility for coordinating some aspects of the home and the support that service users receive. Berryfield Road (19) DS0000028389.V283284.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 has a positive approach to personal development and promoting the rights of service users. Service users are kept well informed and consulted although systems of quality assurance are not well established. Risk assessments and systems are in place, which promote the health and safety of service users. EVIDENCE: Ms Burrows has been the registered manager at 19 Berryfield Road since 1998. Ms Burrows has completed the Diploma in Social Work course since the last inspection and is now making progress with the registered managers award. The staff member spoken with had recently been appointed and commented positively about the support she had received and the running of the home. Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 20 There were seen to be good relationships between the service users, manager and staff members. Ms Burrows reported on recent developments and demonstrated a management approach that is focussed on the needs of the service users. Service users have received their own files containing copies of meeting minutes, correspondence and information about the home. 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 has produced a business plan for the home, which includes developments that will be of benefit to service users. The home’s fire log book was up to date. A health & safety file contained accident reports and general information. One member of staff has responsibility for carrying out an internal and external inspection each month. Items in need of attention are reported in a maintenance book. The manager said that there was no problem with getting repairs done. Generic and individual risk assessments are being undertaken. Berryfield Road (19) DS0000028389.V283284.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 N/A 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 X STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 2 X X 3 X Berryfield Road (19) DS0000028389.V283284.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 YA23 YA30 Regulation 37 23 Timescale for action The Commission is notified of the 31/03/06 outcome of the incident that is referred to under standard 23. The three-piece suite must 31/03/06 receive attention or be replaced to ensure that it is clean and in good condition (The suite has been cleaned, but is to be replaced). C.R.B. / P.O.V.A. information 31/03/06 must be kept in the home, including: • The name of the person • Date of disclosure • Level of disclosure • Including POCA Check (if requested) • Including POVA check (if requested) • Disclosure reference number • Date POVAFirst check was received (if this was sought) and POVAFirst Reference number. Requirement 3. YA34 19(1) Berryfield Road (19) DS0000028389.V283284.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA19 YA23 YA24 YA34 YA35 YA35 YA39 Good Practice Recommendations That a record of foot care, including nail cutting, is maintained in the service users’ health records. That the policy on abuse and POVA is developed to include details of the training that staff will receive and how this will be updated. That the storage arrangements in the garage are improved (met in part since the last inspection). That a recruitment checklist is completed. That greater use is made of outside agencies and trainers in the training that staff receive in areas such as POVA and medication. That L.D.A.F. accredited training is provided for staff who are new to working in a learning disability service. That the policy on quality assurance is developed to include details of how the different devices contribute to the production of an improvement or annual development plan for the home. Berryfield Road (19) DS0000028389.V283284.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 (19) DS0000028389.V283284.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!