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Inspection on 02/08/06 for 19 Berryfield Road

Also see our care home review for 19 Berryfield Road for more information

This inspection was carried out on 2nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The three requirements set at the last inspection which related to information about a specific incident, the replacement or renewal of the three piece suite and how Criminal Record Bureau and Protection of Vulnerable Adult checks were stored in the home, have been met. Each service user has an in depth care plan and their own goals set, which ensures that all their needs are met. Service users are involved in this process as much as possible. Service users have full and active lives and are involved in a wide range of interests and activities with friends, relatives and in their local community. Service users` health, safety and wellbeing is promoted and the manager and staff team actively seek out information in order to do this. Where service users are able to manage aspects of their own lives, they are supported in developing their own skills to do so, maximising their independence. Service users live in a homely and safe environment that meets their needs, where they feel comfortable and relaxed.

What has improved since the last inspection?

There is new furniture in the lounge and service users like the way their sitting room now looks. Other changes have been made to the home to improve it and this includes better storage facilities in the garage, where service users have become actively involved in recycling. The manager in the home has devised a statement about service users receiving personal care from staff who may not be of the same gender, for this particular home and service users who live there. This is an all female service user group and staff team. Work has begun on gathering the views of service users, their families and stakeholders so that a quality assurance process can begin within the organisation as a whole. It is not clear how this will be developed in the service yet as accompanying changes to policies and procedures are recommended. One staff member has gained a National Vocational Qualification at level 3 since the last inspection.

What the care home could do better:

There was a recommendation at the last inspection that the organisation involve external agencies in medication and Protection of Vulnerable Adult training, as this would enhance the training and knowledge available within the organisation. The manager of the home has involved external bodies in other training sessions. This recommendation has been carried forward. 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. Following the meeting with OLPA personnel staff on May 16th 2006, changes will be made to the way records are to be made to the way that staff records are to be held in the organisation and a recruitment checklist will be completed and held in the home. A recommendation has been carried forward so 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.

CARE HOME ADULTS 18-65 Berryfield Road (19) 19 Berryfield Road Bradford on Avon Wiltshire BA15 1SU Lead Inspector Mrs Jacqui Burvill Key Unannounced Inspection 2nd August 2006 11:00 Berryfield Road (19) DS0000028389.V298516.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 (19) DS0000028389.V298516.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 (19) DS0000028389.V298516.R01.S.doc Version 5.2 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.V298516.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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. Fees range from £750 per week. Inspection reports are available in the home. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit to the home took place on 2nd August 2006. This was arranged at short notice with the manager, as on previous attempts to visit the home noone was at home. Pre inspection information was requested before the site visit. Four service user surveys were sent to the home and four were returned. Relative surveys were sent to the home for the manager to distribute and two were returned. One relative commented on the lack of activities at weekends and in college holidays and that the placement was expensive and not providing value for money. The relative had made a complaint and felt this was dealt with helpfully. Part of the inspection was spent looking at the evidence to support this view. None could be found. Further evidence about this can be found in the Lifestyle section, standards 11- 17. There was a tour of the premises and two service users were met with. The following records were looked at; care plans, daily dairies, risk assessments, medication, fire safety records and staff training. Some policies and procedures were also looked at. What the service does well: The three requirements set at the last inspection which related to information about a specific incident, the replacement or renewal of the three piece suite and how Criminal Record Bureau and Protection of Vulnerable Adult checks were stored in the home, have been met. Each service user has an in depth care plan and their own goals set, which ensures that all their needs are met. Service users are involved in this process as much as possible. Service users have full and active lives and are involved in a wide range of interests and activities with friends, relatives and in their local community. Service users’ health, safety and wellbeing is promoted and the manager and staff team actively seek out information in order to do this. Where service users are able to manage aspects of their own lives, they are supported in developing their own skills to do so, maximising their independence. Service users live in a homely and safe environment that meets their needs, where they feel comfortable and relaxed. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There was a recommendation at the last inspection that the organisation involve external agencies in medication and Protection of Vulnerable Adult training, as this would enhance the training and knowledge available within the organisation. The manager of the home has involved external bodies in other training sessions. This recommendation has been carried forward. 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. Following the meeting with OLPA personnel staff on May 16th 2006, changes will be made to the way records are to be made to the way that staff records are to be held in the organisation and a recruitment checklist will be completed and held in the home. A recommendation has been carried forward so 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.V298516.R01.S.doc Version 5.2 Page 7 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.V298516.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 (19) DS0000028389.V298516.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 This standard was not assessed as no new service users have been admitted since the last inspection and the home is full. EVIDENCE: Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 10 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): 6, 7, 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are as involved as possible in deciding aspects of their care needs. They are encouraged to make decisions and choices about their own lives. Where this may involve risks, these have been assessed. EVIDENCE: The four service users’ care plans and shared action plans were looked at. Each service user has their own in depth care plan, which describes their range of needs following assessment and how these are to be met. Service users meet with keyworkers and have one to one meetings at least once a month, and these are used to support service users with their shared action plans. These are plans that enable service users to think of their own goals and what they may like to do in the forthcoming year. Changes are only made to the shared action plan after discussions with the service users. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 11 The care plans are reviewed monthly and there is a checklist to record this. Each month identifies a section of the care plan that has been reviewed. There are sections described include; communication needs, night and day routines, eating and drinking, and leisure activities. There are signposts within the care plan to other documents that support the service user with a particular need. Each care plan contains an anti-discrimination and an anti–oppressive action plan. There are also examples of ethical implications for two service users who may argue from time to time. The daily diary, keyworker meeting notes and tenant meeting notes show how service users are involved in decision making and offered choices about activities inside and outside of the home. These notes were clear and objective, showing how service users had been included and taken part in choices on offer. Each service user has a file in their room, which contains copies of their one to one meetings with staff and tenant meetings. Risks are clearly described and have been reviewed regularly. There are guidelines in place that support service users taking risks as part of an independent lifestyle, such as staying at home alone for short periods of time. During the inspection, service users were observed walking independently to the local shop to get an evening paper. This was clearly a part of their general routine, and one they enjoyed. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16, 17 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users take part in appropraite activites and enjoy the range offered to them. This includes them in their local community and meeting friends and relatives. Service users’ rights and responsibilites are recognised and respected as part of their every day lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: The care plans, daily diaries and activity plans were looked at. Service users also described the range of activities they liked to take part in. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 13 Two service users were looking forward to a short camping trip at Brokerswood and discussed this with the inspector. As a result of one of the comments made on the relative survey, the range of activities were looked at to see if there was a reduction in choice at the weekends or at times when colleges were not open. Service users have very busy lives in the home. Most of them attend day care or college at least 4 times a week and one service user attends college full time and has a part time job. Each service user has a range of activities described and further notes about their involvement in the home and other activities they take part in is recorded extensively and objectively in the daily diary. This record is so precise as to describe each particular activity, of which there may be many in one day. Weekends are just as busy as week times and there no evidence to support the comment made. The notes made include details about when service users go out with their families, or with close friends and show how involved they are in their local community. There are positive relationships with neighbours and the registered manager described a recent BBQ with service users, relatives and neighbours. Service users have made friends with other service users in the OLPA house next door and often meet up and spend time together. Service users have been on holiday with other service users from next door to the new OLPA caravan and enjoyed it very much. One service user is working towards independence and there is evidence showing how staff have supported this by ‘shadowing’ on occasions, whilst confidence is built up. There is a record to show that service users have agreed to a coin operated lock for their bedroom door. This was discussed with the manager, who explained that service users may agree with the manager that is something they want, but say something different to someone else at another time, forgetting what they may have already agreed to. Each service user has their own individual menu record. Meals are chosen for the week ahead and it depends on each day as what will be cooked, as service users may choose to go out that evening and activities and time play a factor. There is an attractive dining room where service users eat their meals. They spoke positively about the meals and the part they played in helping out. Two service users were met with and they both said how much they enjoyed living at 19 Berryfield Road. One service user showed the inspector round the Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 14 garden and the ground floor of the home. Another service user showed their bedroom to the inspector and described how they had chosen everything in it. They also went on to describe how active their life was, especially going out with friends and family. Berryfield Road (19) DS0000028389.V298516.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive personal care and support in the way that benefits them. This includes physical and emotioinal health care needs. There is a positive approach in ensuring service users get the best possible support both inside and outside of the home. Service users are suported to manage their own medication, or parts of it where they have been assesed as able to do so. Service users beneft from safe systems of medication management. EVIDENCE: Service users have a range of healthcare and personal care needs, which are described well in the care plan. This is an all female service user and staff group, and the manager has written some guidelines about providing personal care if the member of staff is of the opposite gender. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 16 There are clear guidelines for staff to follow when supporting service users with managing aspects of their behaviour. There is also information about specific conditions that the service users may have for staff to read and understand. There are charts that have been used to support service users when they may display some challenging behaviour, so that this can be looked at and analysed. These charts have not been needed for some time as staff and the service user have been successful in managing the behaviour. One aspect of this was discussed with the manager, who has been trying to get a base line assessment completed for a service user. The inspector sign posted the manager to some organisations who may be able to help with this. There are sections in the care plan file, which describe healthcare appointments and what action may need to be taken as a result. There is clear evidence about involvement with other health care professionals, such as occupational therapists and action taken to provide suitable equipment. One service user partially self medicates, whilst staff support other service users. Medication and accompanying records were looked at. These were all in order. Each service user has a medication administration sheet. Some of the entries recording the name and dose of medication had been completed by the GP. Each service user has an individual record showing what medication has been received into the home and was has been disposed of. This helps to provide a clear audit trail for their medication and shows it is being safely managed and administered. There is information available about medication used in the home. Medication guidance was discussed and the manager explained that this was being developed within OLPA. Staff have received medication administration training from within the organisation. It was a recommendation from the last inspection that the organisation involve outside agencies in training for medication, as this would enhance the training and knowledge available within the organisation. Berryfield Road (19) DS0000028389.V298516.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ views are supported, listened to and acted upon. Service users are protected from abuse, neglect and self harm by staff who understand how to report and refer to a multi disciplinary team. EVIDENCE: A relative’s comment made on the survey indicated that they had made a complaint. There was no record of this held in the home. The manager described what may have led to this view and how it had been dealt with. At the time the manager dealt with it as a verbal concern and the manager was supported by the service co-ordinator. There is one complaint that has been pursued by a service user against Wiltshire County Council. This has now at the final stage, where it is being reviewed by the panel. The service user has received advocacy support in managing this and has the services of a solicitor. Further signposts were discussed with the manager, such as the Ombudsman and the General Social Care Council. The organisation has devised a range of policies and procedures about how to manage different types of complaints. This describes the procedure for logging Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 18 complaints and referring to senior management, should the complainant not be satisfied with the response. There have been no Protection of Vulnerable Adult (POVA) Referrals since the last inspection. A previous early strategy meeting has now been concluded. There is guidance in the home about adult protection, which is linked to the Wiltshire and Swindon ‘No Secrets guidance. Staff have received internal training in adult protection and signs and symptoms of abuse. There were two previous recommendations that the organisation should develop the policy on abuse and POVA to include details of the training that staff will receive and how this will be updated. There should also be greater use made of outside agencies and trainers in the training that staff receive in areas such as POVA. These have not been met. There are additional policies and procedures on whistle blowing, bullying and harassment. There is a checklist in the care plan about whether service users can manage their finances independently. Some service users are able to manage with support, but at varying levels. The manager has made arrangements to discuss this document with the senior management team in the organisation. One service user money records were checked. This showed a discrepancy of .04p, which was rectified during the inspection. The records show that staff check the balance very frequently and complete a record to say they have done this. Berryfield Road (19) DS0000028389.V298516.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a safe, comfortable, clean and fresh environment. EVIDENCE: 19 Berryfield Road is in a quiet residential area not far from the shopping area of Bradford on Avon. It has four bedrooms on the first floor for service users, a bathroom and a separate toilet. Two service users showed the inspector part way round the home and showed the inspector their rooms. They liked how they were able to have all of their belongings out and said they had chosen the colour scheme in their rooms themselves. On the ground floor, there is a large sitting room, which leads into a dining room and a separate kitchen and a cloakroom. The utility room is in the garage, which has a coating on the floor to make it water resistant. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 20 The previous requirement about the three piece suite receiving attention or being replaced has been met, as there are now a three and two seater sofa. Service users described how much they liked the new furniture and that it was comfortable to sit on. At the last inspection there was a recommendation that the storage arrangements in the garage are improved and this has been met, with better arrangements for storing recycling and shelving for storing items. There is a large garden to the rear of the home, which a slope and handrails and a patio area with table and chairs. The home was very clean, tidy on the day of inspection and smelled fresh. Berryfield Road (19) DS0000028389.V298516.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are working towards achieving relevant qualifications and further training opportuntiies are being developed by the manager and the organsiation that will benefit service users. There is good recruitment practice, with new arrangements for storage of documents being put in place. EVIDENCE: Staff training records were looked at for all staff employed in the home. All staff have received first aid, drug administration, moving and handling, adult protection and fire safety training. Basic food hygiene training is booked for all staff. There is in house training as part of the monthly team meetings. The manager plans to develop further knowledge and training about a particular condition affecting a service user in the home. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 22 There are three staff currently employed in the home and there is one vacancy, currently met by OLPA relief staff. One staff member has a National Vocational Qualification at level 3, one staff member has NVQ level 2 and one is undertaking level 3. There is a trainer within the organisation and further skills development training is being planned in the following areas; freedom, rights and responsibilities, mental health awareness, person centred approach, medication training, which will be linked to National Vocational Qualification standards, infection control and communication. There was a previous recommendation that LDAF accredited training is provided for staff who are new to working in a learning disability service and this has been started across the organisation. One other previous recommendation was that greater use is made of outside agencies and trainers in the training that staff receive in such areas as POVA and medication and this is on going and has been met in part. The manager arranged infection control training recently with an external provider based at Devizes Hospital. The manager has also attended an Adult Care Conference. Staff recruitment records were looked at a site visit to the OLPA head office in May 2006. Records relating to the home were in order. Arrangements will be put in place by OLPA personnel staff, so that staff recruitment records can be held in the OLPA office, with a checklist in the home describing what checks have been made on staff. This new arrangement meets the previous requirement about the storage of Criminal Record Bureau certificates and Protection of Vulnerable Adult checks. No new staff have been appointed since the last inspection. Berryfield Road (19) DS0000028389.V298516.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a well run home, where their welfare and safety is promoted. Service users are contributing to a review of quality in the home and would benefit from a clearer structure about the process. EVIDENCE: The registered manager has been in post for eight years, has a Diploma in Social Work and is completing the Registered Managers Award. The manager described how she intends to further develop the knowledge and skills with the staff team in the home, and has started a file, which describes achievements the home has made. These include activity achievement, such as a family BBQ, the OLPA Summer Fete, a Summer trip with the Gateway Club and a certificate to show that the garden won ‘Best Mature Garden’ in the OLPA competition. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 24 The organisation sent a quarterly newsletter to each home which details news from other homes, recipes, events, competitions, photos and a quiz. The manager has devised a Quality Assurance file, which include Regulation 26 visits from a representative from the organisation. She has also devised a business plan with the finances she is provided with. She has included an analysis of the strengths, weaknesses, opportunities and threats to the service. The manager has developed an internal system for measuring quality. 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 has started to devise a system for gathering the views of service users, relatives and other interested parties. Managers have been asked to send questionnaires out so that information about these views on the quality of the service can be assessed. The form includes a section for comments and for people to think about one thing the organisation could do better. The quality assurance policy and procedure comments on the range of ways that quality had been assessed and this included Regulation 26 visits and other methods. The policy and procedure needs to be amended to reflect this process. This should include the aims of the questionnaire and how the organisation plans to implement any changes that may be suggested. Fire record checks were looked at and these were all in order, which checks taking place at the appropriate times. There are good health and safety checks and systems in place in the home. Berryfield Road (19) DS0000028389.V298516.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 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 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 2 X X 3 X Berryfield Road (19) DS0000028389.V298516.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations 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. COMMENT: Carried forward from the last inspection. That a recruitment checklist is completed and held in the home. That greater use is made of outside agencies and trainers in the training that staff receive in areas such as POVA and medication. Comment: Carried forward from the last inspection. 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. COMMENT: Carried forward from the last inspection. Action DS0000028389.V298516.R01.S.doc Version 5.2 Page 27 2. 3. YA34 YA35 4. YA39 Berryfield Road (19) is being taken to gather the views of service users, relatives and stakeholders. Berryfield Road (19) DS0000028389.V298516.R01.S.doc Version 5.2 Page 28 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. 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