Inspection on 22/01/07 for 55 Berryscroft Road

This inspection was carried out on 22nd January 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

55 Berryscroft Road 11/05/07

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 Suzanne Magnier Unannounced Inspection 22 January 2007 12:00 nd Berryscroft Road (55) DS0000067596.V329833.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.V329833.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.V329833.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.V329833.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-65 YEARS 17th October 2005 Date of last inspection 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.V329833.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced visit formed part of the key inspection and took place over five hours commencing at 12 midday and finishing at 17.00 at the registered care home. Ms S Magnier Regulation Inspector conducted the inspection with the registered manager and the visit was announced in order that the inspector could meet with the residents and staff at the home. For the purpose of this report, the home has requested that people using the service are referred to as residents. The home are currently offering a residential service to 6 residents and employs 10 members of staff who work flexibly over the two services owned by Brand Homes Ltd. The inspection process included the sampling of documents which consisted of residents care plans, risk assessments, daily records, medication records, several policies and procedures; staff training details and staff recruitment files. Comments from residents and staff have been included in the report. These were obtained during the visit. The Commission for Social Care Inspection have also received written comments from healthcare professionals, which have also been included in the report. The inspector would like to thank the resident’s, staff and the manager for their assistance and hospitality during this visit. What the service does well: The home has a flexible yet structured atmosphere, which promotes the residents rights to freedom of choice in their home. The home has robust care plans, based on a person centred approach and supports resident’s to maintain active, stimulating and meaningful activities in the community. Encouragement is given to residents to maintain links with family and friends and promote new friendships. Risk assessments are well managed. Staff recruitment, induction and training files are well recorded and staff spoke favourably of the day-to-day management of the home. Berryscroft Road (55) DS0000067596.V329833.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.V329833.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.V329833.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): 1,2,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have sufficient information to make an informed choice if they would like to live in the home and trial periods of stay in the home are available. The arrangements for a needs assessment for new residents are adequate to ensure the needs of prospective residents are assessed and identified before admission to the home. Residents have a copy of their terms and conditions of stay in the home. EVIDENCE: The homes statement of purpose and service users guide remains available for prospective residents. Trial periods to the home according to the needs and preferences of the residents are arranged and can include overnight stays. There have been no admissions to the home since the last inspection in August 2005. The inspector sampled two residents files which evidenced that the home had undertaken assessments of the prospective residents needs, their likes and dislikes including activities, meals, preferences of their daily routines for example getting up in the morning, having a meal and also how the resident prefers to communicate. The inspector met with one resident who had moved into the home in the summer of 2005 and they told the inspector that they ‘loved living at the house and had made many friends’. Each Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 9 resident file sampled contained a copy of the terms and conditions of residency in the home. The home has maintained a close bonds between the residents and staff and it is apparent through observation that the resident’s diversity of needs and preferences of lifestyles are promoted to ensure that all resident’s continue to have a sense and awareness of their individuality. Berryscroft Road (55) DS0000067596.V329833.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has maintained robust care planning and risk assessments. The documents were current and well recorded to ensure the residents wellbeing and health needs were evidenced as being met. Residents make decisions regarding their lives and participate in the running of their home. EVIDENCE: The home has continued to improve the standard of care plans to include person centred awareness. The two care plans sampled by the inspector contained evidence that each resident had been involved in the development of the plan to reflect their lifestyle, goals and achievements. There was clear guidance for staff of how the resident prefer to be addressed, receive support or supervision with their personal care, what meals they like and what support was needed, if any, with their activities both in and outside of their home. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 11 One care plan detailed the changes in a resident’s needs and how the home were continuing to offer support and encouragement to the resident. The support included the use of ‘objects of reference’ to assist the resident to understand and have continued control over their daily life. The manager explained the importance of routine and continuity of care for the resident in order that their daily life was predictable and as stress free as possible. The home had obtained specialist advice and support from a speech and language therapist, psychologists, specialist health care professionals and a dietician in order to ensure the needs of the resident continue to be monitored. It was evident through sampling records and observation in the home that staff members continued to support residents with diverse needs in a caring and individualised way in order to promote resident’s individuality and sense of identity. The home has a flexible yet structured atmosphere, which promotes the residents rights to freedom of choice in their home. The resident’s daily records were seen by the inspector and were respectfully and well written by staff. The records included information about the resident’s daily activities, the support given by staff, any change in the health needs and actions taken, and how the resident had participated in their day. The residents care plans included a variety of goals and ambitions of each resident which reflected their diversity to include support to the local place of worship, the need for solitude and quiet and an understanding of the residents needs in response to their anxiety. Records indicated that one resident has an advocate who offers ongoing support to the resident. It was observed that the staff responded promptly and appropriately to the individual needs of the residents during the site visit. Several residents told the inspector that they liked living in the home and written comments included ‘I feel comfortable I can put my feet up if I want’; I get on very well with the others and its my home;’ ‘I like living here as it makes me happy, staff help me build my self esteem’; ‘I can go to church every week’. The home has continued to maintain individual documented risk assessments. The assessments sampled were well recorded to detail the activity or behaviour being presented, the hazard and actions taken to minimise the risks of harm. Some risk assessments included being in the kitchen, making drinks, going to the shops, bathing/showering, shaving, horse riding, making sandwiches and support for behaviours which may ‘test’ the service including clear guidance for staff to offer a structured and consistent response to the resident in order to calm the situation. Berryscroft Road (55) DS0000067596.V329833.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home promotes and maintains residents involvement in their community, offers opportunities for personal development, appropriate activities and maintaining friendships. Residents are encouraged to be involved in the running of the home and improving daily living skills. The available choice of food provided was of a good standard. EVIDENCE: The atmosphere in the home during the evening was busy with the residents eagerly wanting to tell the inspector what they had been doing since we last met. The inspector noted that the residents chatted between themselves and were happy to be home after being out all day. Several residents made themselves a cup of tea, went to their bedrooms or sat watching television in the communal lounge. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 13 Several residents told the inspector what they had been doing which included drawing and painting, horse riding, going to the cinema, going to the local shops and into town and also keeping in touch with friends and family. Residents also attended a local day service where one resident said they had ‘lots of friends’ and ‘liked going there’. One resident told the inspector ‘ I love it here, I’ve been bowling and keeping fit today’, There was evidence that the home supported the diversity of choice as one resident who liked to smoke cigarettes told the inspector that there is a smoking area by the back door and they smoke there as other people might not like the smell and that they do not smoke in their bedroom. Another resident told the inspector that they has been helped by staff to lose weight and this had helped their self esteem and they felt much better. The care plans sampled indicated that residents received staff support to do some of the housework, which included hovering, dusting, cleaning their bedrooms and polishing. The washing machine is in the utility area next to the kitchen and residents, with staff support participate in loading their washing into the machine, or fold their washing with staff support if needed. Residents were free to move around the kitchen safely. One resident helped a staff member prepare the evening meal by peeling the vegetables and also make sandwiches for their packed lunch for the next day. The resident looked on the notice board in the kitchen and told the other residents at home what was for supper. The inspector sampled the homes recording of meals taken by the residents. The records indicated a varied diet, which included vegetarian dishes as well as meat dishes. Food serving temperatures were also recorded. The residents told the inspector that they can chose what they want to eat although one comment card stated ‘I don’t choose what I eat’ and another stated ‘I sometimes go shopping for food’. The homes fridges and freezers contained had a variety of foodstuffs and fresh fruit and vegetables were also available. The inspector noted that in the homes refrigerator several items including angel delight and tinned fruit salad were stored in the fridge without covers and dated at the time of use. This was brought to the manager’s attention and the shortfall rectified immediately by disposing of the food. The manager explained that he would address the shortfall with staff individually and in a staff meeting. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has consistent recording and documentation to evidence that residents attend health care appointments to ensure their wellbeing and welfare. The homes medication procedures are generally robust yet the home must ensure that all medication charts are signed following resident’s administration of medication in order to ensure their safety and wellbeing. EVIDENCE: The two resident care plans sampled by the inspector included a health care checklist, their body weight chart, clear records of health care appointments attended for example visits to the dentist, optician, GP and chiropodist. Both care plans also included records regarding Community Care Assessments for example occupational therapist and speech and language therapists. Additional records also included appointments to psychiatrists, psychologists and other specialist healthcare professionals. Records indicated that some care plan review had taken place yet the manager explained that it was difficult to arrange reviews due to the shortage of care managers and any queries were generally dealt with through the ‘duty’ system. It was noted that the manager Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 15 and staff were active in seeking advise and support from healthcare professionals should the need arise to ensure the safety and well being of the residents. The home has a comprehensive, recently updated, medication policy and procedure regarding administration of medication. The home has a Monitored Dosage System (MDS) system, which is overseen by the manager. The medication is stored in a locked cabinet in order to protect the residents from harm. The inspector sampled all the resident’s medication administration charts all of which were generally in good order. It was noted that on a few occasions staff had not signed that the medication had been administered or refused and it is required that arrangements are made to ensure that all medication charts are accurately completed to demonstrate safe administration of residents medication to ensure their wellbeing and safety. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure to demonstrate that complaints will be acted upon and a Safeguarding Adults (Adult Protection) policy and procedure in order that residents are adequately protected by the same policy and procedure. EVIDENCE: During the site visit the inspector asked several residents what they would do if they had any concerns. The residents said they would go to the manager or staff and would feel confident that their concerns would be listened to and dealt with. The home has a complaints procedure and the manager explained that no complaints have been received by the home. The manager explained that all staff had received training in safeguarding vulnerable adults. The inspector spoke with the manager and a staff member on different occasions who explained the appropriate procedures for reporting any allegation of abuse in line with the local authority safeguarding vulnerable adults policies and procedures. There have been no safeguarding referrals since the previous inspection. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home offers a comfortable and homely environment. Resident’s bedrooms reflect individuality. Cleanliness and maintenance of furniture in resident’s bedrooms must be improved to ensure safe standards of hygiene and safety in the home. Communal areas, including bathrooms in the home were spacious, well decorated and maintained to meet the current needs of the residents. EVIDENCE: The home continues to offer a homely and comfortable environment. The inspector observed that the lounge had been redecorated and new leather sofas had been purchased offering adequate seating for the residents and their visitors to the home. A new carpet had been fitted throughout the house. The dining area was well decorated and offered adequate space to meet the needs of the residents to enjoy their meals. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 18 During the tour of the premises the inspector sampled all bedrooms one of which had been decorated. The shared bedroom was noted as being dirty for example the skirting board and sink, one residents bedding was soiled, the room was noted as unkempt and dusty, rotting apples were found in the waste bin, there was a lack of ventilation and the suitcases under the bed, with shoes and toys in and contained a layer of dust. It was evident that the residents in the room had not been offered support to keep their room clean and tidy. It is required that after consultation with the environmental health authority, the home must make suitable arrangements for maintaining satisfactory standards of hygiene in the home including resident’s bedrooms. The shared room furniture remains in a state of disrepair and the requirement from previous inspections have not been met. The manager advised that the redecoration and refurbishment would be attended by April 2007 and a quotation of cost had been agreed. The manager explained that he had hoped to have the room redecorated and refurbished some months ago however in consultation with one of the resident’s care manager’s the arrangement for one resident to reside at the relatives home of another over a weekend period was deemed by the care manager as unsatisfactory. It is recommended that the manager seek further advise from the resident’s care manager in order to ascertain what arrangements can be made to accommodate the resident whilst the shared room is being refurbished. A further requirement has been made that the registered person must provide in rooms occupied by residents adequate furniture and equipment suitable to the needs of the resident and ensure that the broken wardrobe door, drawers and broken cupboard under the sink in the shared room must be replaced or repaired. In each of the bedrooms there were personal possessions, furniture and leisure items which included televisions, music and photos. The inspector noted that the residents bedding was not matching and the manager explained that the bedding is stored in a large cupboard in the staff sleeping in room, and resident’s help themselves to the bedding. On further discussion the manager advised that at times other residents do use the bedding of another resident. It has been recommended that each resident have their own bedding stored in their room to promote the resident’s sense of individuality and independence regarding ownership of their belongings. The home has one bathroom and a shower room and toilets are available in each room. Both bathrooms are well decorated. The general state of decoration, maintenance, cleanliness and hygiene in the communal parts of the home was good. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home have improved the induction and training development and recruitment of staff procedures to ensure the safety and well being of residents. Further improvements need to be developed regarding staff recruitment practices to promote the homes equal opportunities policies and procedures to ensure the protection of residents. EVIDENCE: It was observed that the staff on duty were confident and competent in supporting and encouraging the residents. There was a sense of ease and resident’s spoke favourably about the staff, with some mentioning their favourite staff members by name. The majority of staff are employed to work over the two services owned by Brand Homes Ltd with the staff working flexible shifts to accommodate the needs of the residents. Whilst sampling staffing records the inspector noted that overall recruitment practices had improved for example an updated job description, application form and a structured induction programme. On sampling the recruitment records it was noted that there was a lack sufficient of evidence for example Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 20 person specification, short listing criteria or interview records, to support that prospective employees had received a structured interview and equality of opportunity and anti discrimination practices had been upheld. It is required that further development of staff recruitment practices include evidence of a detailed person specification, short listing criteria and interview records, to promote the homes equal opportunities policies and procedures to ensure the protection of residents. The staff files sampled evidenced that the manager undertakes safe vetting practices including appropriate references and Criminal Records Bureaux checks. (CRB). Staff training and induction records were sampled to evidence that staff have undertaken and have achieved distance-learning courses covering all mandatory training. There is regular support and advise available from community health care professionals for example speech and language therapists who commented ‘ I have only just started having dealings with the home. I have no reason to believe that they would not fulfil their obligations in their entirety’. Specialist training has also been made available to staff for example dementia awareness and some staff have experience and skills working with people who may ‘test’ the service. Five staff members are currently undertaking their National Vocational Qualification (NVQ) Level 2 and the deputy manager is currently undertaking her Level 3 NVQ. One staff member told the inspector that they had worked at the home for many years and the training opportunities had really improved the staff’s abilities to support residents. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is adequate. 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. Specific areas of resident’s safety and welfare need to be improved. EVIDENCE: The home continues to be well managed and runs efficiently. The registered manager has achieved the registered managers award, which has promoted a renewed sense of competency and confidence in the running of the home. The philosophy and values of the home are evident and resident’s views about their home included ‘‘I can keep my things private but I don’t have a cupboard with a key’ ‘I feel comfortable I can put my feet up if I want’, ‘ I get on very Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 22 well with the others and its my home.’ I sometimes like living here’ ‘I have a front door key’ ‘I like it here’. The manager explained that the home had undertaken a quality assurance questionnaire recently and were waiting for the result to be returned. It was evident during the inspection that the residents were able to voice their opinions about the service and that the staff would be attentive and respond to any improvements that the residents wanted. The home has resident meetings, which are attended by residents if they choose to. The inspector sampled a variety of health and safety records, which included fridge and freezer temperatures, accident and incident records, fire drills, practices and noted the home has smoke detectors in place. Fire extinguishers had been serviced in January 2007. Records indicated that the home undertake regular checks of the water temperatures in the home however the inspector noted that the water thermometer was broken. The manager advised that a new thermometer was on order and would be delivered to the home the following day. It has been required that the registered person shall ensure that unnecessary risks to the health and safety of residents are identified and as far as possible eliminated including risks from hot water. The home had recently had all electrical appliances and the gas boiler checked. The last environmental health visit had been undertaken in 2005. A monthly health and safety record was seen by the inspector, which was completed by the manager each month. During the tour of the premises the inspector noted that all the residents bedroom doors were not closing properly. The manager took prompt action regarding this shortfall and an engineer visited the home immediately. The engineer advised that he would return to the property within the week to repair the shortfall. It is required that all fire doors within the premises must be in full working order to ensure that safety and welfare of all residents. Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 1 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 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 2 X 3 X 3 X X 2 X Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13.(20) Requirement The registered person must ensure that arrangements are made to ensure that all medication charts are accurately completed to demonstrate safe administration of prescribed medication to ensure the wellbeing and safety of residents. The registered person must provide in rooms occupied by residents adequate furniture and equipment suitable to the needs of the resident and ensure that the broken wardrobe door, drawers and broken cupboard under the sink in the shared room must be replaced or repaired. Not met on 16.8.05. & 24.1.06. The registered person shall after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the home including resident’s bedrooms. The registered person must DS0000067596.V329833.R01.S.doc Timescale for action 06/02/07 2. YA26 16.(2)c 22/04/07 3. YA30 16(2)(j) 05/02/07 4. YA34 18.(1)(a) 22/02/07 Page 25 Berryscroft Road (55) Version 5.2 5. YA42 6. YA42 further develop the staff recruitment practices for example evidence of detailed person specification, short listing criteria and interview records, to promote the homes equal opportunities policies and procedures to ensure the protection of residents. 13.(a)(b)(c) The registered person shall ensure that unnecessary risks to the health and safety of residents are identified and as far as possible eliminated including risks from hot water. 23.(4)(a)(c) The registered person must (i)(iv) ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety and that fire doors are fully self closing. 26/01/07 26/01/07 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 YA26 Good Practice Recommendations It is recommended that the manager seek further advise from the resident’s care manager in order to ascertain what arrangements can be made to accommodate the resident whilst the shared room is being refurbished. It has been recommended that each resident have their own bedding stored in their room to promote the residents sense of individuality and independence regarding ownership of their belongings. 2. YA26 Berryscroft Road (55) DS0000067596.V329833.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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