Inspection on 11/05/07 for 55 Berryscroft Road

This inspection was carried out on 11th May 2007.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

55 Berryscroft Road 22/01/07

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

CARE HOME ADULTS 18-65 Berryscroft Road (55) 55 Berryscroft Road Laleham Staines Middlessex TW18 1ND Lead Inspector Kenneth Dunn Unannounced Inspection 11th May 2007 09:00 Berryscroft Road (55) DS0000067596.V338287.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 Berryscroft Road (55) DS0000067596.V338287.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. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berryscroft Road (55) Address 55 Berryscroft Road Laleham Staines Middlessex TW18 1ND 01784 459404 01784 459404 brandhomesltd@btinternet.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Brand Homes Limited Mr Jon Reginald Brand Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd January 2007 Brief Description of the Service: 55 Berryscroft Road is small care home for six people with learning difficulties who are younger adults. Mr J Brand is the Proprietor and Manager and operates the care home with an emphasis on a domestic and homelike atmosphere. The house is set in a residential street in Laleham close to public amenities. The house offers four single bedrooms and one twin bedroom and shared communal and laundry facilities. There is a medium sized rear garden with a seating area and barbeque. The house has a friendly atmosphere and all residents participate fully in the running of their home. The current range of fees are £447.19- £1,045.49 per week. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over four hours commencing at 10.00 am and ending at 14.00 pm and was undertaken by Mr Kenneth Dunn, regulation inspector and Mr Jon Brand the registered manager representing the service. For the purpose of this report, the manager has requested that people using the service are referred to as residents. At the time of this visit the home is registered to offer care to up to six residents. All the key inspection standards for Younger Adults were assessed. The Statement of Purpose, the Service User Guide, assessment documentation, care plans, risk assessments, medication records and a sample of quality assurance questionnaires and other monitoring forms were audited. Staff personnel files were sampled and recruitment documentation reviewed. Individual induction and training records were also sampled. Policies and procedures, menus and health and safety records were viewed. The Commission for Social Care Inspection received written comments from the residents and healthcare professionals, which have also been included in the report. The inspector would like to thank the management, the staff and residents of 55 Berrycroft Road for their assistance and hospitality on the day of the site visit and those who completed comment cards or spoke to the inspector for their contribution to this report. What the service does well: The information available to residents is in a format, which they are able to understand. The service has developed systems for supporting the residents to achieve their full potential. The manager and staff are dedicated to ensuring that the residents have the confidence and life-skills to enable them become as independent as their individual potential allows them to be. The home had a ‘person centred’ style of care planning, which meant that the care and support provided was based on what the service user wanted and needed rather than what was easier to deliver, and they were involved as fully as possible in the planning of their care. The home has developed strong links with the local community and made good use of the facilities and resources available. Residents had a full programme of activities based on their individual needs and choices Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 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 Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 & 2 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is available in appropriate formats to enable residents or their representatives to make choices about the service meet their needs. All prospective resident’s care needs and aspirations are assessed prior to a place being offered to ensure the home can meet them. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed in January 2007 it was well designed and informative. The information contained within the statement of purpose and the service users guide would offer the reader a clear picture of the services provided and the care offered at the home. The service has not admitted any new residents since August 2005. The inspector sampled resident’s files, which contained a full assessment of the individuals. The assessments were detailed and included full descriptions of the likes and dislikes of the person creating a rounded picture of the individual before they move into the home. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and personal goals are reflected in their individual Person Cantered Plans (PCP’s). The residents are supported to make decisions about their lives. In addition they are consulted and their views are respected in the running of the home. EVIDENCE: The resident’s files sampled contained detailed person-centred planning (PCP’s), which had been compiled in conjunction with the individual residents and staff. The PCP’s clearly illustrated the resident’s favourite activities, and hobbies and important people in their lives. In addition the resident’s aspirations and wishes were also recorded. Individual plans were written in way which focused on fully on the individual and included personal care needs, domestic skills, communication, safety in the community, shopping, leisure activities, group living, personal relationships, health, education and choice/consent. The completed PCP’s were signed and dated by the resident and all other relevant parties. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 10 The files all contained detailed risk assessments the manager stated that they are regularly reviewed and reassessed by staff to ensure that they are current and relevant to the individual. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to take part in a wide range of activities in the community. The staff ensures that all appropriate personal relationships are maintained. EVIDENCE: There is clear written evidence in the residents individual files and in the daily logs that they make frequent use of local facilities and go out to eat, the cinema and places of interest. The residents are fully supported by members of staff who regularly assist them to go shopping for their toiletries, clothing and footwear. All outings are subject to risk-assessments. The inspector observed staff supporting the diversity of choice of one resident who liked to smoke cigarettes. The home had made arrangements for him to use a smoking area by the back door, the resident understood why he had to Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 12 use this area and stated the he did not mind “ as other people might not like the smell”. The residents are support by staff to undertake basic household tasks, vacuuming the communal areas, dusting and cleaning their bedrooms. On the day of the visit one resident was very industriously cleaning her bedroom to the accompaniment of her favourite music and was delighted to show the results of her efforts to the manager and the inspector. The residents are supported to work in the kitchen to prepare their own coffee, tea and snacks. The staff are responsible for preparing the main meals of the day a sample of the menus indicated that the residents received a varied diet, which included vegetarian dishes as well as meat dishes. The inspector was informed by one resident that he could get something different if he did not want what was being offered as the main dish. The same resident told the inspector that staff were helping him to lose weight because he had a medical condition that needed to be controlled. A member of staff explained the process used at home to support the resident and documents sampled supported the actions being undertaken by the staff. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 13 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): Standards 18, 19 & 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents receive appropriate support according to their assessed needs and individual wishes. The service is dedicated to ensuring positive action is taken with regard to all health issues. EVIDENCE: The resident care plans sampled by the inspector included a health care checklist, which included a weight chart, health care appointments attended to the dentist, optician, GP and chiropodist. In addition the plans contained detailed records regarding Community Care Assessments with various health professionals including occupational and speech and language therapists. Additional records also included appointments to psychiatrists, psychologists and other specialist healthcare professionals. The manager stated that the service was dedicated to providing the residents with appropriate support and to achieve this the staff actively seek the advise and support from healthcare professionals to ensure the safety and well being of the residents. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 14 The home has a comprehensive set of medication policies and procedure regarding administration of medication. The home has a Monitored Dosage System (MDS) system, which is overseen by the manager. All medications are stored in a locked cabinet in order to protect the residents from harm. The inspector sampled the resident’s medication administration charts all of which were generally in good order. A recommendation was made to complete risk assessment for residents to self medicate, at the time of the visit all resident’s medication was handled by the staff. In discussion with the manager it was felt that a review of this policy should be undertaken and a set of risk assessment completed to ensure that this is best practice for the residents. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 15 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): Standards 22 & 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear guidance in an appropriate format for the protection of the residents. The residents are supported and encourage too express their views and issues. The policies and procedures in place are designed to protect residents from harm. EVIDENCE: The service has a complaints policy, which is contained within the Service User guide and the employee’s handbook. There have been no complaints made directly to the CSCI and a review of the complaints log would indicate that there have been no complaints made to the manager since the previous inspection. A member of staff confirmed that as a group they were aware of the local authority Safeguarding Adults Procedure, a copy of which was available in the office. Training had been regularly up-dated to ensure the residents were protected from harm. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26 & 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole the residents live in a homely, comfortable, clean and safe environment, which is effectively meeting their needs. EVIDENCE: The home fulfilled the collective needs of the residents in a homely and comfortable way enabling them to enjoy the maximum amount of independence in a non-institutional way. However the shared bedroom has continued to be an area where the manager has not fully complied with requirements from previous reports. The service has purchased new furniture for the shared room part of this order has been delivered and fitted, however there are still outstanding items not as yet on site. The manager stated that the complete refurbishment of this area would be fully completed by the end of May one month later than had been planned. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 17 The outside areas of the home also require attention the patio to the rear and the paved are at the front of the property have cracked, broken concrete slabs and in several areas they have become uneven because of weeds pushing through. Therefore two requirements have been made please refer to page 23 of this report. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 18 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): Standards 32, 34 & 35 were assessed. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The staff group appear to be well trained, skilled and in sufficient numbers to support the residents. The service provider has system in place for the safe recruitment, induction and the training development of staff to ensure that the resident’s needs are met appropriately and safely met. EVIDENCE: Observations of the staff working with the residents throughout the site visit confirmed that relationships were respectful and that residents were listened to and their wishes acted upon. Training records showed that a high percentage of staff had completed National Vocational Qualifications (NVQ) at level 2 and 3 in care. In addition to the mandatory training, which records confirmed, was regularly updated, the staff were encouraged to access a variety of courses to assist them with the caring role and to meet the needs of the residents. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 19 Staff personnel files sampled confirmed that all the recruitment checks had been completed prior to the offer of a post. The manager stated that no new staff have employed since the previous inspection on the 22nd of January 2007. The manager has developed a set of equal opportunities procedures however they have not yet been implemented. The manager stated that the policies have to be checked for there legal standing prior to them being fully introduced as a working procedure. Therefore a requirement has been made please refer to page 23 of this report. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 20 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): Standards 37, 39 & 42 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is robust, residents and their representative’s views and opinions are considered. The manager has actioned a safety audit to ensure that the resident’s safety and welfare is maintained at a high level. EVIDENCE: Feed back from residents and observations made during the site visit would indicate that the home continues to be effectively managed. The registered manager has relevant qualification including the Registered Managers Award. From conversations with a member of staff and residents feedback, it was clear that the manager is highly regarded. The manager stated that feedback is actively sought from the residents and acted upon in order to ensure that they can maximise their own potentials Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 21 The inspector reviewed the completed quality assurance questionnaire they demonstrated that there is a high level of satisfaction by residents living at 55 Berrycroft Road. It was evident during the inspection that the residents were able and encouraged to talk to staff and the manager about the service they receive. The home had policies and procedures in place for health and safety. All the necessary safety checks had now been undertaken and recorded and copies of safety certificates were held on file. Staff had received training in Health and Safety, Control of Substances Hazardous to Health, Fire Safety, Food Hygiene and the Protection of Vulnerable Adults Procedures. There was an ongoing programme of maintenance and repair. The manager must however undertake a review of the arrangements for residents smoking within the building to ensure that the service will comply with future government legislation. Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 22 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 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 2 26 2 27 X 28 X 29 X 30 3 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 3 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 Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 23 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. 2. Standard YA24 YA26 Regulation 23. (2) o 16. (2) c Requirement The front and rear gardens must be maintained regularly. The CSCI must be provided with confirmation of finalisation of the refurbishment of the shared bedroom. The provider must provide the CSCI with a detailed and documented plan for the full and final implementation of ongoing works. The recruitment policy must be fully introduced as a working procedure of the service. The smoking policy must be reviewed in order to meet changes within government legislation. Timescale for action 30/06/07 01/06/07 3. YA34 18. (1)(a) 30/06/07 4. YA42 13. (4) c 01/07/07 Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 24 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 YA20 Good Practice Recommendations The manger should complete risk assessment for residents to self medicate or to be assisted by staff Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Berryscroft Road (55) DS0000067596.V338287.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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