Inspection on 06/04/05 for Berecroft Home

This inspection was carried out on 6th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 but made no statutory requirements on the home.

Other inspections for this house

Berecroft Home 04/06/07

Berecroft Home 21/04/06

Berecroft Home 21/10/05

Berecroft Home 10/09/04

Berecroft Home 23/04/04

Berecroft Home 16/12/03

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Paradise Lodge

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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 6th April 2005 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Berecroft Home Address 317 Berecroft Harlow Essex CM18 7SH 01279 410859 01279 442309 www.essexcc.gov.uk Essex County Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Susan Anne Crowley Care Home 25 Category(ies) of Learning disability (25) registration, with number Learning disability over 65 years of age (4) of places Berecroft Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 25 persons) 2 3 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 Date of last inspection 10th September 2005 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in April 2005. Twenty-four of the Forty-three standards were inspected, of these two were exceeded, nineteen were meet, the remainder being partially met. A tour of the premises took place and both care and staff records were inspected. Three of the seven care staff on duty were spoken to, as were five of the twenty-five service users residing at the home. What the service does well: What has improved since the last inspection? The issue raised at the last inspection regarding the offensive odour in the room of one of the service users has been acted upon, and is much improved. The annexe bungalow, which at the time of the last inspection was being used for storage, has now been totally refurbished, and has been registered with the Commission for Social Care Inspection to provide a one to one service for a young gentleman who, it would appear, has settled into his new home very well. Berecroft Home Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Berecroft Home Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Berecroft Home Version 1.10 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 standard(s) 2 and 5 The home’s admission process contained detail of service users’ wishes and aspirations.. EVIDENCE: The contracts of residency clearly identified what was provided by the service to the service users. The home has appropriate admission arrangements which clearly link service users’ needs and wishes to services provided. Service users are admitted to the home via external Social Services’ referrals and have a Community Care Assessment. In addition, the home has its own residential assessment proforma, which covers all the sub sections of the National Minimum Standard. Three service users’ contracts of residency were sampled; they contained details of the services provided and available to service users in residence. Berecroft Home Version 1.10 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 standard(s) 6 and 7. Care planning systems are clear and appropriate. EVIDENCE: Service users’ care plans are comprehensively detailed and contained clear evidence of service users’ needs and wishes. Service users have appropriate access to advocates. Three service users’ care plans were sampled and seen to contain comprehensive detail; monitoring sheets were attached to each care plan to ensure that they were continually kept under review. Staff spoken with during the inspection evidenced their knowledge in relation to the care plans. Discussion with the support team manager indicated that some service users have formal advocates. The care plans sampled were seen to contain active records, where an infringement of a service user’s rights had occurred. Evidence was presented of this infringement of rights being necessary to maintain positive relations within the local community for a service user accessing the local community services. Berecroft Home Version 1.10 Page 10 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 standard(s) 12, 13 and 16. Social activities are generally well managed. The home provides a range of appropriate activities for service users, both within the home and the local community. EVIDENCE: Discussion with the support team manager indicated that two service users participate in paid part-time employment, with another service user partaking in part-time voluntary employment. Four service users attend the local Education College, where they participate in the following classes: • • • Flower arranging Cookery Creative clay In addition, other service users attend the local Day Centre, from where they access a range of activities including trampolining and drama. Berecroft Home Version 1.10 Page 11 Service users are supported to attend the local church services. The support team manager spoke of service users using the local shops. A service user spoken to during the course of the inspection spoke of being a member of the local social club. All service users have keys to their rooms. One service user spoke of having unrestricted access to all communal areas of the home. Berecroft Home Version 1.10 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 standard(s) 19. Evidence reflected that the health care needs of service users are managed effectively. EVIDENCE: Three service users’ files were sampled. All service users are registered with a General Practitioner. Records of input from healthcare professionals were comprehensively detailed and adequately maintained. Berecroft Home Version 1.10 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 standard(s) 22 and 23. The home’s complaint procedure was seen to be available in pictorial format, for ease of use by service users. The Adult Protection and Whistle Blowing policies were both adequate to protect service users from harm or abuse. EVIDENCE: The home had received two complaints since the last inspection. Records were presented that indicated that the complaints received had been resolved to the satisfaction of the complainants. The home maintains a complaints and compliments log for the recording of complaints and compliments received. The complaints policy is available in pictorial format for ease of use by service users. Berecroft Home Version 1.10 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 standard(s) 24 and 30. The environmental standard of the home is good. The houses visited were seen to be homely and comfortable. EVIDENCE: The home’s premises were observed to be fit for their stated purpose, being safe and accessible. All four cottages were homely and decorated to a good level and furnishings were seen to be suitable to the needs of the service users. The odour issue identified at the last inspection has been much improved. On the day of the inspection the home was generally clean and tidy, and free from any offensive odours. Service users observed and spoken to during the course of the inspection appeared to be very happy and proud of their home. Berecroft Home Version 1.10 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36. The procedures for the recruitment of staff were seen to be safe in terms of protecting service users. The deployment of staff was adequate to meet the basic needs of service users, but left very little scope for spending quality time with service users. EVIDENCE: The home currently has four staff who are NVQ qualified, with a further four registered to commence the award, two of whom are close to completion. In addition, the home has two NVQ assessors. Staffing continues to be reviewed as the needs of the service users change, this currently being seven carers throughout the day, nights are covered by three waking night staff and one sleep-in staff. The manager is supernumerary to the staffing levels. Discussion with a visiting Social Worker and staff on duty during the course of the inspection indicated that the staffing levels at the home are adequate to meet the basic needs of the service users, but leave little room for any real quality time to be spent with service users. The home needs to review its staffing levels using the residential forum as recommended by the Department of Health. Berecroft Home Version 1.10 Page 16 Three staff files were sampled in respect of the home’s recruitment process. All three files were seen to contain the documentary evidence required under Regulations. Training needs of staff continue to be identified through the supervision process, from which a personal development plan is developed. All newly appointed staff are registered for the LDAF (Learning disability Award Framework). Discussion with the registered manager indicated that formal supervisions are taking place every four-six weekly. The manager spoke of maintaining records to ensure that all of her staff who are responsible for providing supervision are up to date. Staff providing formal supervision have not received any formal training. It was recommended that the provision of such formal training should be considered. Berecroft Home Version 1.10 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 and 43. It was evident that generally staff feel they receive guidance and direction from the manager, although some concern was raised in respect of the managers openess and approachability. EVIDENCE: The registered manager of the home is qualified at NVQ Level 4 in management. In addition, the manager has a number of years’ experience of working in the care sector. Discussion with staff during the course of the inspection was mixed in terms of the manager’s openness and accessibility and, in some cases, their approachability. The manager has disseminated questionnaires to relatives and carers, and is in the process of further developing questionnaires to be disseminated to other professionals. The organisation is in the process of developing its quality Berecroft Home Version 1.10 Page 18 assurance process corporately, but in the meantime the manager spoke of their intention to continue disseminating questionnaires. The home has corporate policies and procedures; the manager spoke of discussing individual policies with staff during team meetings. In- house policies are in the process of being signed off by the registered manager. Records required by regulation for the protection of service users were seen to be in order. A sample of safety certificates were viewed and seen to comply with requirements. The home is run by the Local Authority, which allocates an annual budget; funding is then allocated across key areas of responsibility. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 Berecroft Home Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 Standard No Version 1.10 Score Page 19 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x x x Score 24 25 26 27 28 29 30 STAFFING 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 x Standard No 31 32 33 34 35 36 Score x 3 2 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 3 3 Berecroft Home Version 1.10 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 YA 33 Regulation 18 Requirement 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. This is a repeat requirement.. Timescale for action June 2005 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 YA 36 Good Practice Recommendations It is recommended that staff who are providing formal supervision receive training for the role. Berecroft Home Version 1.10 Page 21 Commission for Social Care Inspection Address 1 1st Floor, Fairfax House Causton Road Colchester 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 Version 1.10 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!