Inspection on 04/06/07 for Berecroft Home

This inspection was carried out on 4th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berecroft Home 21/04/06

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 Pauline Dean Unannounced Inspection 4th June 2007 09:45 Berecroft Home DS0000034845.V342305.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 Berecroft Home DS0000034845.V342305.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. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 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.V342305.R01.S.doc Version 5.2 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 April 2006 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 is divided into four cottages and one bungalow, which have a total of twenty-five single bedrooms. 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.V342305.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 of Berecroft took place on 4th June 2007 over a 5hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last inspection in April 2006, looking at records and documents at Berecroft and talking to Mrs Susan Crowley, the registered manager and care staff. A tour of the premises was also completed. Questionnaires were left with the manager for distribution to all of the people living at Berecroft, and two were completed and returned at the time of writing this report. In addition questionnaires were left for distribution to family and friends and healthcare professionals, but none of these have been returned to the Commission. Following the site visit, the Annual Quality Assurance Assessment (AQAA) was completed and returned to the Commission. The information contained in both the surveys and the AQAA has been used in this report. During the site visit four people who live at Berecroft were spoken with. All were pleased with the service and happy about way they are supported and assisted by the staff. They said that they liked their rooms and were keen to tell us about the social and leisure activities they were attending. Twenty-two National Minimum Standards were inspected. This included all key standards. Two requirements and three recommendations were made as a result of this inspection, with all outcomes detailed as good. In line with the Commission’s vision and values of ‘putting people who use the services first’ this summary has also been produced in a separate ‘easy read’ version. Copies of this summary are to be made available to the people who live in the home and they are created using The Inspection Picture bank, which is based on themes within the National Minimum Standards. What the service does well: Berecroft continues to provide good support in a homely environment. The home is well managed, with a good team of staff who have a clear understanding of their roles and responsibilities and the needs of the people living at the care home. Opportunities for both leisure and educational activities are sought by the home for individuals living at Berecroft and people living at the home were pleased with the social lives they led. There was evidence of a variety of activities and outings experienced by the people living at Berecroft. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 6 As at the last inspection staff and management praised the training opportunities on offer. Evidence was seen of both basic and individual training course attendance e.g. Food Hygiene, Adult Protection, Fire safety and Moving and Handling, with individuals attending courses in British Sign Language and training on epilepsy and diabetes awareness. 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. Berecroft Home DS0000034845.V342305.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 Berecroft Home DS0000034845.V342305.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): 2. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A comprehensive admissions process ensures that people who come to live at Berecroft are assured that their needs are met. EVIDENCE: On the day of the site visit there were twenty-five people living at Berecroft. Mrs Susan Crowley said that there are no vacancies at the home and there have been no emergency admissions. An Emergency Admission Protocol was in place. The admission paperwork for a person living at the home was sampled and inspected. They were admitted in August 2006 with a review of their placement in October 2006. A detailed assessment had been completed by the home and documentation had been received from the local authority to support the placement. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 9 Within the survey work completed by the Commission for Social Care Inspection (CSCI), two people had responded. One person living at the home said they had chosen Berecroft as they wished ‘to be close to my family,’ whilst a second person said that they ‘had no choice’. ‘In 1977 I was put here for one night.’ Berecroft Home DS0000034845.V342305.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, 8, 9 and 10. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documents were comprehensive detailing health, personal and social care needs. Regular reviews were in place to ensure that the people who use the service receive the care they wish and require. Risk assessments enable the people living at Berecroft to take manageable risks. EVIDENCE: Three care plans were sampled. All three care plans were comprehensive detailing care planning goals, in one case there were 20 care plan goals in place. Care plan goals covered social, health and emotional care needs. Evidence was seen of monthly reviews and detailed record keeping. To support the care plan file, each person had a Daily Activity Folder, which linked in with the care plan goals set. Each plan was based upon a needs assessment. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 11 Prior to writing this report the Annual Quality Assurance Assessment was completed by the care service. In this document the registered manager spoke of ‘individual person centred care plans, that identify choices and individual aspirations, individual risk assessments’. They spoke of pictorial forms of information/choices such as staff rotas, activity choices/boards and menu planning. These were evident on the inspection. Evidence was seen on all three files of in put from the people who live at the home. Both staff and two people who live at the home said that they were able to make decisions about their lives. They spoke of being able to make decision as to what they did in the home and what they wished to do outside the home. Risk assessments were in place alongside the care plans. Sampling of the three files, risk assessments were seen evidencing that the people living at Berecroft were 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 individuals to ensure that the risk was minimised. Berecroft Home DS0000034845.V342305.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 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The daily routine and activites in the home were flexible and optional, with people who live at Berecroft being encouraged to make choices with regard to their social, cultural, religious and leisure activities. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. Links with the local community are encouraged and promoted. Berecroft provides a varied and nutritious menu for individuals to select from. EVIDENCE: Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 13 Within the sampled care plans and daily activities files there was evidence of a wide variety of activities in which the people who live at Berecroft are supported to take part in. There was evidence of individuals attending a day centre and college courses, shopping, having meals out local restaurants, visiting local public houses, theatres and cinemas, playing snooker and playing football in a recently formed football club. One person spoken to say that had attended their cookery class that day and they spoke with enthusiasm about the activities of the day and what they had enjoyed cooking. Holidays are planned and arranged by each cottage and the people living at the cottage. Cottage 2 had arranged three holidays, to Bognor Regis, Centre Parcs and a cottage in Yorkshire. Some staff have accessed support and training in food nutrition and with this and the development of our pictorial guide, which supports service users choice, whilst promoting a healthy eating lifestyle has assisted us, improve this element of our support and development to the service users here at Berecroft. It was evident from sampling the care plans and from speaking with four people who live at Berecroft that they are encouraged and supported to be part of the local community. One spoke of playing snooker at a local public house, another spoke of going to collage and two spoke of attending a day centre. It was evident that these external activities gave great enjoyment and promote self-confidence. No relatives were visiting the home at the time of the visit. The registered manager confirmed that the home has an open door policy regarding visiting arrangements and in each cottage there was a quiet room, which could be used by the people who live at the home and their visitors. Visitors were said to visit the home during the week and over a weekend, with the home supporting and enabling these visits. One person living at the home said that they were able to visit their parent regularly and this was obviously enjoyed a great deal. Surveys were left at the home for relatives of the people living at the home, but none had been completed and returned to the Commission at the time of writing this report. Throughout the day the people were seen going about the home at they wished. They were not restricted and were able to use the communal garden areas at the front of the cottages. Seating areas had been developed there and care staff said that communal barbeques are held here. Staff were seen to interact positively with the people living at Berecroft and during the day we saw evidence of joking and banter between the people living at Berecroft and the people caring for them. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 14 Survey work completed by the Commission for Social Care Inspection (CSCI) asked the question – Do you make decisions about what you do each day? and each person had replied that they were sometimes able to make such decisions. No explanation was offered in these surveys as to the circumstances around making decisions. Menu planning and nutrition record keeping was sampled in one of the cottages (Cottage 3). Some gaps were found in the record keeping and the detail of meals taken outside the home was not sufficient. Weight charts were kept for some individuals in the home as was appropriate for their care. A three-week menu plan was in place with colour coded shopping lists developed from these menus. Care staff and the registered manager confirmed that each cottage undertakes their own shopping and in the cottage sampled, two of the people living at the home are involved in the weekly shopping and budgeting. Within the menu planning consideration is taken of special diets i.e. diabetics and meal times are planned to suit the people living in the home with the main meal of the day in the evening, the only exception being on Sunday when the main meal is at lunchtime. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s arrangements for supporting the healthcare of the people living at the home was detailed to enable staff to know what action is required and what action is to be taken. EVIDENCE: As we spoke to the people living at Berecroft it was evident that they were able to make choices with regard to getting up in the morning and going to bed at night. Care planning documents and records evidenced this. During the site visit we were able to observe staff going around the home supporting the residents and ensuring that at all times their privacy and dignity was supported. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 16 A tour of the premises highlighted that there were a range of aids and adaptations within the home to enable the people living at Berecroft to be supported in their independence. From sampling care planning documents and records, it was evident that the people living at Berecroft were able to access healthcare professionals such as GPs, Dentists, Opticians and Hospital Consultants. The registered manager said that the home uses three to four local GP surgeries and they receive a good service. One person spoken to said that they were either taken to the doctors or the doctor visited them at home when they needed to see a doctor. Medication administration, record keeping and storage was sampled and inspected in one of the cottages (Cottage 3). Overall this was well managed with record keeping detailing the giving of medicines, with appropriate coding used as needed. Clarification was sought from the registered manager as to the giving and using of ‘homely’ remedies. One person was said to have had paraceatmol, multi-vitamins and Venos and this needed to be added to the Medication Administration Record (MAR) sheet. No entries were found on the MAR Sheet for a second person and again homely remedies were given. The home needs to review current practice with regard to the giving and recording of homely remedies in line with their medication policy and procedure. Clarification was also sought at the management of medication coming into the home. Medication was recorded and checked on individual MAR sheets, but it was not clear if there was a central record system for recording medication entering and leaving the home or being disposed of. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 13. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Berecroft were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: Within the Annual Quality Assurance Assessment the registered manager spoke of viewing the home’s complaints/compliments policy as an integral part of their quality monitoring of the service. The Annual Quality Assurance Assessment stated that all people living at Berecroft and their families were given a ‘How to Complain’ document. This has been produced in a pictorial form is used to explain the process to the relatives and people living at the care service. At the site visit, the registered manager said that all complaints/ compliments are logged and responded to within set timescales and this was evidenced through inspection of the complain log. The management of complaints was detailed and through with a clear audit trail of the process and outcomes seen. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 18 Berecroft has a robust protection of vulnerable adults policy. Two staff spoken to at the site visit confirmed that they had received a copy of this document and had a good understanding as to the need for referral. The registered manager said that staff receive ongoing training in safeguarding adults and this is access through Essex County Council. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, Berecroft provides a safe environment that is accessible to the people who live at the home. It is homely and meets individual’s needs. EVIDENCE: Berecroft comprises of accommodation for 25 people. At the time of the site there were 25 people living at the home in the four cottages and one bungalow. A tour of the premises was completed at the site visit and each cottage was light and bright and homely. Within each cottage there were a kitchen and laundry facilities, which enable the people living at Berecroft to participate in these tasks and skills, as they are able. Furnishings, fittings and furniture were of a high standard and were individual to each cottage and to the people living in the cottages. The maintenance and Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 20 decoration of the home was seen to be ongoing with both a maintenance management company appointed by Essex County Council and a Gardener/Handyman employed. The property was well maintained with action taken or programmed as soon as issues were noted. As stated previously in this report the home has a range of specialist equipment to meet the needs of individual of the people living at Berecroft and these are all maintained and serviced regularly, by approved contractors. In the twelve months the following areas have been decorated lounge areas(2), a hallway and landing, bedrooms(3) with replacement flooring in 2 bedrooms. Replacement washing machines, tumble dryers, cookers and fridge freezers have been installed as required since the last inspection. An Environmental Health inspection took place on 14th June 2006 and there were no requirements and a Fire Service Inspection had taken place on 5th January 2007 with a recommendation made regarding fire drills and instructions to take place at regular intervals. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to ensure the people who live at Berecroft are safe and their individual needs are addressed. Berecroft has a good staff team and the people who live at the home are protected by the home’s recruitment practices and training. EVIDENCE: Berecroft has a robust staff recruitment procedure in place. Three staff files were sampled and inspected. There was evidence of a detailed application form with full employment history and at least two references had been obtained for each applicant. The people who live at Berecroft are involved in the selection process, for the home involves their advocates in this process. Two care workers interviewed at the site visit confirmed the practice and process of recruitment. Each spoke of being interviewed, with both references and Criminal Record Bureau (CRB) Enhanced checks being completed before Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 22 they started their employment. Both care staff members were enthusiastic and keen on the staff training opportunities offered. The registered manager spoke of new staff completing an induction-training course and this was confirmed by the two care staff interviewed and evidenced in the records. The registered manager said that all new staff now complete induction training within the Learning Disabilities Award Framework (LDAF), which has a National Vocational Qualification (NVQ) level 2 in care for people working with people who have a learning disability. Within Berecroft there is a staff training and development programme. The completed Annual Quality Assurance Assessment speaks of 12 care staff having NVQ level 2 or above. In addition a further two staff are undertaking NVQ level 3 in care. Two staff interviewed at the site visit confirmed that they were enrolled on a NVQ level 3 course in care and the third carer said they had completed both NVQ level 2 and 3. Training at Berecroft is given a high profile and as well as the registered manager, the home is able to draw on the skills of a support team manager who holds a NVQ assessors award. Within the Annual Quality Assurance Assessment, the registered manager states that a further support team manager is due to undertake their assessor’s award in the Autumn. From the Annual Quality Assurance Assessment it is understood that an audit of training has been completed and this has assisted with the clarity of the required mandatory training areas. On staff files there was evidence of training courses completed including a variety of mandatory training courses such as Food Hygiene, Adult Protection, Fire safety and Moving and Handling. In the Annual Quality Assurance Assessment it is stated that as well attending these basic training courses all staff have completed a Risk and Conflict Management training and Fire Awareness training. The majority of training is offered in-house through Essex County Council, but it was evident that the home does look elsewhere for specialist training courses such as the British Sign Language training and training on epilepsy and diabetes awareness through their local Primary Healthcare Trust. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Berecroft benefits from clear management structure. People who use this service do not benefit from a developed quality assurance and quality monitoring system. Safe working practices are promoted through ongoing training. Health and safety certification and insurances promotes a safe working environment. EVIDENCE: Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 24 The registered manager is well qualified and experienced. Mrs Susan Crowley has a NVQ level 4 in care and has over 10 years experience of working with adults with learning disability. Mrs Crowley said that she has been able to update her skills through attending a variety of basic training courses as they have been offered to staff e.g. courses on autism, epilepsy, invasive techniques training, an adult protection seminar and a moving and handling refresher course. In addition she said she had attended training on management tasks such managing finances and managing sickness. In discussion with Mrs Crowley it became clear that she did not have a level 4 NVQ in management. Guidance from the Commission was sent to Mrs Crowley to consider how she can meet this requirement. From speaking to care staff (2) it was evident that staff consider the registered manager to be considerate and supportive. They said that they had regular 1:1 supervision sessions and records were seen on their files. Training opportunities were also said to be very good and both staff interviewed were enthusiastic and keen to attend different training courses some of which they personally had identified as being of particular use to them as individuals. At the site visit evidence was seen of a Service Users’ Survey conducted in November 2006. An analysis of the outcomes of these surveys had been completed, but no action plan had been developed. It could be seen however, that some action had been taken e.g. a garden had been enclosed at one of the cottages and changes had been made to menus following comments regarding the food served at Berecroft. Whilst this is seen as a start to a quality assurance and a quality monitoring system, the home still needs to develop an annual development plan based on a systematic cycle of planning-action-review, reflecting aims and outcomes for the people living at Berecroft. The health, safety and welfare of the people living at the care home is promoted and protected through the promotion of good working practices through training courses detailed earlier in this report. Within the Annual Quality Assurance Assessment document the registered manager states that the home ensures regular testing and safety certifications as required by legislation. Sampled and inspected at the site visit was the Electrical Installation certificate of 28th November 2002 with a lifespan of 5 years and the Gas Safety and the Landlord/Gas Safety Record dated 5th June 2006. Following the site visit, the registered manager emailed confirmation that a Gas safety check had been completed on 14th May 2007. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 X 26 X 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 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13(2), 17 Requirement People who use this service must be assured of a good service through the management and record keeping of medication entering the home, leaving the home and being disposed of. People who use this service must be assured of a good service through the development of a process for reviewing and keeping under review the quality of the home’s service provision. This is a repeat requirement from the last inspection. Timescale for action 31/07/06. Timescale for action 19/10/07 2. YA39 24 19/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 27 1. YA17 2. 3. YA20 YA37 People who use this care service should be assured that nutrition records have greater detail of the food eaten when going out for a meal and a detailed report should be kept of all meals taken. People who use this care service should be assured that the management and administration would be managed through a medication policy on the homely remedies. The registered manager achieves NVQ level 4 in management. Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Extracts may not be used or reproduced without the express permission of CSCI Berecroft Home DS0000034845.V342305.R01.S.doc Version 5.2 Page 29 - 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. 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