Inspection on 21/04/06 for Berecroft Home

This inspection was carried out on 21st April 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berecroft Home 04/06/07

Berecroft Home 21/10/05

Berecroft Home 06/04/05

Berecroft Home 10/09/04

Berecroft Home 23/04/04

Berecroft Home 16/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Berecroft Home 317 Berecroft Harlow Essex CM18 7SH Lead Inspector Neal Cranmer Key Unannounced Inspection 21st April 2006 09:30 21/04/06 Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Berecroft Home Address 317 Berecroft Harlow Essex CM18 7SH 01279 410859 01279 442309 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) www.essexcc.gov.uk Essex County Council Mrs Susan Anne Crowley Care Home 25 Category(ies) of Learning disability (25), Learning disability over registration, with number 65 years of age (4) of places Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 25 persons) Four persons of either sex, aged 65 years and over, who require care by reason of a learning disability The total number of service users accommodated in the home must not exceed 25 persons 21st October 2005 Date of last inspection Brief Description of the Service: Berecroft care home is owned and managed by Essex County Council. It provides accommodation and care for people with a learning disability over the age of eighteen. The home works with service users to develop their daily living and independence skills. The home has one shared bedroom and twenty-three single rooms. Service users have the opportunity to attend a day centre or access community based resources. The home is well maintained with pleasant gardens. A local shop, church and public transport are all within easy walking distance of the home. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on 21st April 2006 with the assistance of the registered manager, service users and staff. The site visit was carried out between the hours of 9.30 am and 3.00 pm Service users and staff were spoken with and records and files were examined. During this process a total of seventeen key standards were inspected, of which sixteen were met, the remaining one being a major shortfall. What the service does well: The home provides support in an environment that is homely and maintained to a good standard. It is well managed and service users are supported by a team of staff who have a good understanding of their roles and responsibilities. Both the manager and staff have a good understanding of the service users’ support needs. Staff spoken with confirmed that the home provided good training opportunities. Sampling of the training database evidenced that the following training was being provided: • • • • • • Manual handling Epilepsy awareness Risk and conflict Adult protection Food hygiene First aid. All staff spoken with stated that access to formal supervision was good and regularly provided. Team meetings are aimed for on a weekly basis, although in practice the registered manager stated that they were taking place at least monthly. What has improved since the last inspection? The home’s Statement of Purpose and Service Users Guide have both now been reviewed and meet with requirements. The requirement from the last inspection for all areas of the home to be kept clean and tidy has now been addressed, with the laying of a replacement carpet that was previously noted to be very badly stained. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 6 Discussion with the registered manager evidenced that staffing levels at the home are currently undergoing review. Staff recruitment files sampled were now found to meet with regulatory requirements. 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. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: The home’s Statement of Purpose and Service Users Guide has been reviewed and now meets with regulatory requirements. Four service users’ files were sampled, each of which was seen to contain copies of both documents. The requirement from the previous inspection has now, therefore, been met. Key Standard 2 was met in full at the inspection of 21st October 2005 and continues to include clear and professional assessment criteria. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users are supported by staff to make choices about their every day lives. EVIDENCE: Service users’ care plans were comprehensively detailed and documented, care objectives were clear, as was the guidance to staff as to how to support the service user towards meeting the identified objectives. All the plans seen evidenced that reviews had taken place. Each plan was based upon the needs assessment. Evidence was seen of service users being provided with information designed to enable them to make choices and decisions about their every day lives. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 10 Sampling of service users’ risk assessments evidenced that service users are supported to take risks as a part of developing independent lifestyles. The records sampled were clear and concise in respect of identifying the nature of any risk and the guidelines to be followed by staff supporting the service user to ensure that the risk was minimised. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 16. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service’ Service users are supported to maintain links with the local community which enrich both their social and educational opportunities. EVIDENCE: Service users are supported to partake in activities that are age and peer appropriate. A number of service users residing at the home attend day occupations. Social activities outside the home are well managed and were evidenced to include a variety of leisure pursuits available to service users should they wish to partake. These included: • • • Visits to local public houses Meals out Attendance at clubs DS0000034845.V290115.R01.S.doc Version 5.1 Page 12 Berecroft Home The home has pleasant gardens to the front which on the day of the visit a number of service users were witnessed to be sitting out taking in the pleasant weather. No relatives were visiting the home at the time of the visit, however discussion with the registered manager confirmed that the home has an open door policy on the receiving of visitors, with service users being free to choose where to receive their visitors; to facilitate this each cottage has a quiet room. Staff were witnessed interacting positively with service users and not exclusively with each other. Service users were seen to have unrestricted access to all areas of the home and garden. Standard 17, pertaining to meals and mealtimes, was not inspected on this occasion but was met in full at the inspection of 21st October 2005. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Evidence indicated that service users’ needs are met in a personal way; visits by healthcare professionals are carried out in privacy. EVIDENCE: The home operates a key worker system. Those spoken with were able to provide examples of ways in which service users are supported to maintain their privacy and dignity. One service user was very clear in being able to state that they choose the times at which they retire to bed and get up in the morning. Evidence indicated that service users are supported to be involved in the choosing of which staff work with them. Tour of the premises indicated that a range of aids and adaptations designed to enable service users to maximise their independence were available at the home. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 14 All service users are registered with a local general practitioner. Records pertaining to service users’ healthcare needs were seen to be well documented, with there being clear evidence of access to the following professionals: • • • • • District nurses Dentists Opticians Community nurses Social workers. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key standards 22 and 23 were inspected and were fully met at the inspection of 21st October 2005. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users live in an environment that is safe, homely and comfortable. There was evidence of refurbishment having taken place in some areas. EVIDENCE: Key Standards 24 and 30 were inspected and met in full at the inspection of the 21st October 2006. At the previous inspection a carpet in the downstairs bedroom of a service user residing in cottage 3 was found to be very badly stained. This has now been replaced and the overall appearance of the room was much improved. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users are supported by a team of staff who are well managed and who have a good understanding of their roles and responsibilities. EVIDENCE: The home employs twenty-one care staff. Of these five are qualified at NVQ Level 2, four at Level 3, one at Level 4. In addition, a further four are working towards the award. Three staff are registered for the LDAF (Learning Disability Award Framework) a further two members of the management team are also qualified NVQ assessors. Staff recruitment files sampled were all found to contain all the documentary evidence required under Regulation 19, Schedule 2 of the Care Homes Regulations. Staff spoken with during the course of the inspection confirmed that access to training was good. Access and availability of formal staff supervision was described by staff as being good. Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 18 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): 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence; this included a visit to the service. The home needs to further develop a process for reviewing and keeping under review the quality of its service provision. EVIDENCE: Discussion with the registered manager indicated that there is no formal quality assurance mechanism in place to assess the home’s ongoing service provision. However, Regulation 26 reports are provided to the CSCI on a monthly basis. The pre-inspection questionnaire submitted evidenced that policies and procedures are up to date and kept under review. The maintenance record sheet of the pre-inspection questionnaire provided to the CSCI on 26th January 2006 evidenced that the home’s safe working practices are well maintained/monitored and up to date Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 19 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 x 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 X 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 3 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x x x 2 x x 3 x Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement The registered person must develop a process for reviewing and keeping under review the quality of the home’s service provision. Timescale for action 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Berecroft Home DS0000034845.V290115.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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