Inspection on 21/10/05 for Berecroft Home

This inspection was carried out on 21st October 2005.

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 4 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 21/04/06

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 Unannounced Inspection 21st October 2005 09:30 Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 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.V256748.R01.S.doc Version 5.0 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.V256748.R01.S.doc Version 5.0 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) 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.V256748.R01.S.doc Version 5.0 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 6th April 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.V256748.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in October 2005, lasting 5.5 hours. The inspection process included: discussions with service users, the registered manager and staff. There was a tour of the premises which included observation of service users’ rooms, bathing and toilet facilities, as well as communal areas. During the course of the inspection a range of documentary evidence was sampled. Sixteen of the forty-three standards were inspected, of which ten were met, five were minor shortfalls, with the remaining one being a major shortfall. What the service does well: What has improved since the last inspection? What they could do better: At the previous inspection one requirement was identified pertaining to the need to keep staffing levels under review. To date there has been no evidence to suggest that this requirement has been addressed; the evidence suggested that the staffing levels remain the same, and indeed this requirement is highlighted again in this report. The home’s Statement of Purpose and Service Users Guide both require reviewing to reflect the current position at the home. Risk assessments require further developing to ensure that the guidance to staff is clear and easily accessible. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 6 Floor coverings in some bedroom areas need to be replaced or, at the very least cleaned, as there was evidence seen of some being badly stained. Staffing levels require reviewing as evidence suggests that although the levels are adequate to meet basic care needs, they appeared to leave little scope for anything beyond basic needs. The home must ensure that its staff recruitment processes meet with statutory requirements. Staff providing supervision to others would benefit from receiving some formal training for the role. 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.V256748.R01.S.doc Version 5.0 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.V256748.R01.S.doc Version 5.0 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. Both the Statement of Purpose and Service Users Guide were well detailed to enable service users to make a choice about the home, although both required reviewing to reflect the current status of the home. EVIDENCE: The home’s Statement of Purpose and Service Users Guide were both sampled, and both were in need of review to reflect the current number of service users for which the service is registered. Both also required further review to include the up to date details of the registered manager. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10. Evidence presented indicated that service users are supported to take risks as part of developing an independent lifestyle. Service users’ confidentiality is well protected by the home’s policies and practice. EVIDENCE: The risk assessment for the most recent admission to the home was sampled, which clearly identified the potential risks and who may be affected should the identified risk present. The plan identified the actions to be taken by staff to minimise the risk, however the reference system to the respective care plan was haphazard and difficult to link with. The home has a missing persons procedure to be followed in the event of a service user going missing. In addition, the home maintains a personal profile on each service user which contains the following personal details: • • • Height Hair colour Eye colour DS0000034845.V256748.R01.S.doc Version 5.0 Page 10 Berecroft Home • • • Weight Any distinguishing marks Any known illness, e.g. epilepsy, diabetes The home has a policy on confidentiality and the manager spoke of confidentiality being a topic discussed with staff during their induction. Personal records pertaining to service users are maintained securely, and staff are provided with guidance about how and who to provide information to. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 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): 15 and 17. Service users are supported to maintain links with family and friends, and the home has an open door policy on receiving visitors. Service users are provided with a healthy and nutritious diet. EVIDENCE: The home has an open door policy on the receiving of visitors, and service users have a choice around where to receive their visitors. The manager mentioned that meals could be provided to relatives. The menu plan is one of the cottages was sampled, which evidenced that the diet provided was varied and nutritious. A record of food consumed by service users is maintained. The food stocks sampled on the day were good, and there was evidence of fresh fruit being available. Meals were provided three times daily, at least one of which was seen to be cooked. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Service users are protected by the home’s policies and procedures for the dispensing of medications. EVIDENCE: The medication procedure was sampled in one cottage and found to be in order; records pertaining to administration were in order. Staff at the home administer medication only after completion of the Essex County Council’s medication workbook. In addition, the registered manager spoke of carrying out in-house training periodically to keep staff practice under review. Service users’ records of medication all contained copies of medications they received, which included guidance for staff on possible side effects. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home’s Complaint and Adult Protection procedures and policies are robust in terms of ensuring that service users are protected from possible harm or abuse. EVIDENCE: The home has a complaints procedure, which was available in pictorial format for ease of use by service users. The procedure included details of how to refer to the local office of the Commission for Social Care Inspection. The home maintains a log for the receiving and recording of complaints. Since the previous inspection two complaints had been received by the service, both of which were evidenced to have been resolved. The home follows the Essex County Council’s guidelines for protecting vulnerable adults. However, the registered manager has developed their own in-house policy which identified the various forms which abuse may take and the actions to be taken by staff upon receipt of an allegation of abuse. All staff have received training in adult protection either externally or in-house. Each cottage has a complete copy of the Essex County Council’s guidelines and each member of staff has received a copy of the guide. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 14 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, 26 and 30. The environment in which the service users live is homely, comfortable and safe. Service uses’ bedrooms visited were equipped to meet their individual needs and were personalised. However, the floor covering in the ground floor bedroom of cottage 3 was very badly stained. On the day of the inspection all of the areas of the home visited were clean and tidy and free from any unpleasant odours. EVIDENCE: The home is safe and accessible and generally well maintained. The home is in keeping with the local community and is accessible to all service users. Furnishings and fittings were domestic in nature and were of a reasonable quality. Service users’ bedrooms visited were equipped with the necessary furniture and fittings to meet their individual needs, and evidence was seen of personal possessions. The floor covering in the ground floor bedroom of cottage 3 that was visited was very badly stained. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 15 Each cottage has its laundry room, which is situated well away from food preparation areas; each has domestic style machines which, if required, have sluicing facilities. Each room has hand-washing facilities available. On the day of the inspection all the cottages visited were clean and tidy and free from any offensive odours. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 16 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): 33, 34 and 36. Staffing levels continue to be those cited at the previous inspection and are deemed to be adequate to meet basic care needs. However, they would benefit from being reviewed as a matter of urgency. Further development is required to ensure that the home’s recruitment practices are sufficiently robust to ensure that service users are protected. Indications would suggest that staff are well supported, however supervisors would benefit from some formalised training in providing effective supervision. EVIDENCE: Staffing continues to be seven carers throughout the day, spread across the five cottages. This equates to two carers in cottage 4 from 07.30-08.30 with one staff member in each of the four remaining cottages, plus a duty officer. The registered manager’s hours are supernumerary to the rostered hours. Nights are covered by three waking night staff and one sleep-in staff. To date the home’s staffing levels have not been reviewed using the recommended guidance. The staffing levels would seem to be adequate to meet basic care needs, but would benefit from urgent review. Three staff files were sampled in respect of the home’s recruitment practices. The staff file of the most recent employee employed was sampled. There was Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 17 evidence of a Criminal Records check having been requested, but the one on the file was post 26th July 2004 and subsequently did not comply. The registered manager spoke of formal supervision taking place monthly. The registered manager supervises the support team managers who each then support up to six community support workers. To date staff providing supervision have not received any formal training in providing supervision. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 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): 37 and 38. Service users are supported by a team of staff who are managed by a registered manager who is appropriately qualified and who ensures a positive ethos and management style. EVIDENCE: Discussion with staff indicated that the management team are generally open and accessible. All staff spoken with spoke of feeling able to approach the management team with any areas of concern and all felt that the manager provided a clear sense of leadership and direction. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 1 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Berecroft Home Score X X 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 X X X X x DS0000034845.V256748.R01.S.doc Version 5.0 Page 20 Yes 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 YA1 Regulation 6 Requirement The registered person must ensure that the Statement of Purpose and Service Users Guide are kept under review and revised as required. The registered person must ensure that all parts of the home are kept clean and tidy. The registered person must ensure that the staffing establishment of the home is reviewed periodically or whenever the needs of the service users change, using the recommended guidance. The timescale set for the previous requirement was not met. The registered person must not employ staff at the care home without having obtained all of the relevant documentary evidence required under Regulation 19, Schedule 2 of the Care Homes Regulations. The timescale set for the previous requirement was not met. Timescale for action 31/12/05 2. 3. YA6 YA33 23(d) 18 31/12/05 31/12/05 4. YA34 19, Schedule 2 31/12/05 Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA36 YA9 Good Practice Recommendations It is recommended that staff who are providing formal supervision receive training for the role. It is recommended that risk assessments be reviewed to ensure that they are clear and concise and easily accessible. Berecroft Home DS0000034845.V256748.R01.S.doc Version 5.0 Page 22 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.V256748.R01.S.doc Version 5.0 Page 23 - 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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