Inspection on 29/01/07 for Berehill House Nursing Home

This inspection was carried out on 29th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Berehill House Nursing Home 26/01/09

Berehill House Nursing Home 19/01/06

Berehill House Nursing Home 03/05/05

Berehill House Nursing Home 29/01/05

Berehill House Nursing Home 07/10/04

Berehill House Nursing Home 14/08/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Berehill House Nursing Home Jobsons Close Newbury Road Whitchurch Hampshire RG28 7DX Lead Inspector Val Sevier Key Unannounced Inspection 29th January 2007 09:30 X10015.doc Version 1.40 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 Berehill House Nursing Home DS0000012205.V324452.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 Older People. 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. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berehill House Nursing Home Address Jobsons Close Newbury Road Whitchurch Hampshire RG28 7DX 01256 893087 01256 896795 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) Hestia Care Limited Care Home 30 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (30) of places Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: Berehill House Nursing Home is a home for service users in the category of older persons. The home is located close to a small village. The building is a large old detached property, which was totally refurbished in 2006. The home provides 2 Bathrooms with assisted baths and WC’s, 2 shower rooms with WC and 1 standard bathroom with WC. In addition there are 4 WC’s situated around the home and these are close to communal facilities. The home has a passenger lift for access to all floors and there are also suitable call facilities in all rooms, bathrooms, WC’s and communal areas. There are aids, hoists and assisted toilet and bathing facilities and handrails are situated around the home. There were a total of 25 bedrooms for service users and these were broken down as follows: 13 single bedrooms, 8 single en-suite rooms, 1 double bedroom and 3 double rooms with ensuite facilities. The fees at the home are varied and based on assessed need and range between £327 & £900. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 29th January 2007, during which the inspector was able to have discussions with staff and have interaction with the service users at the home. In addition 6 relatives had completed questionnaires prior to the visit. During the visit to the home a tour of the premises was carried out which included a sample of bedrooms. Staff and care records were sampled and in addition to speaking with staff and service users, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection This is the first visit to the home for 18 months when the home has been occupied. The home was visited in August 2006 following a total refurbishment to establish that the home met the National Minimum Standards. The last inspection of the home when it was occupied was in 2005. The manager has recently been registered with CSCI and assisted the inspector throughout the visit. On the day of the visit there were 16 residents living at the home. What the service does well: Residents and staff expressed very positive views about living and working in the home and the former particularly appreciated the homely atmosphere that the staff helped create. Residents also felt that the home’s staff looked after their needs well and staff members perceived the quality of care provided by the home as “good”. Staff reported generally amicable working relationships. All residents and the majority of staff spoken to expressed confidence in the home’s manager. The general consensus of residents about the food provided by the home was that it was “good”. Residents’ financial affairs were safeguarded and that as far as possible residents’ were able to exercise self-determination and their civic rights. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 7 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. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedures included assessments of the needs of potential residents before they moved into the home to ensure that the home could provide the care and support that individuals required. The home provides information to enable prospective residents and their representatives to make an informed decision about the home and what it offers. EVIDENCE: The manager showed the inspector the service users guide and statement of purpose, which have been altered to reflect the refurbishment that has been carried out at the home. The inspector viewed three pre admission assessments and was able to speak with a resident and their relative about their views of the move to the home and the assessment of needs. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 10 The home had written policies and procedures concerned with the admission of new residents to the home and these referred to the importance of ascertaining the help required by potential residents before they moved into the home. The inspector sampled three records of residents who had been admitted to the home since the last inspection. It was apparent that new documents were being used by the home to record information about potential residents before they moved into the home. Residents spoken with confirmed that senior members of staff from the home met with them before they moved into the home to see what help they needed. • “The nurse visited me at the hospital and made some notes”. • “The matron came to see us before he moved to the home. We were able to ask questions and I visited the home to see it for myself before we made our mind up”. The pre-admission assessments were complemented by other monitoring tools used to assess resident’s needs when they actually moved into the home. There was documentary evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were plans of care in place that ensured that residents received the basic help and support that they needed. However there were needs identified that had no plan of care for staff to follow. The home’s procedures and systems for ensuring that medicines were managed and administered safely were satisfactory. EVIDENCE: The home had written policies and procedures concerned with the admission of new residents to the home and these referred to the importance of ascertaining the help required by potential residents before they moved into the home. The inspector sampled three records of residents who had been admitted to the home since the last inspection in 2005. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 12 There were care plans that identified support needs for individuals, examples seen included: * maintaining a safe environment. * mobility. * dressing and washing * eating and drinking. It as noted however that there was no plan to assist with the mental health needs of those that have dementia. The home has recently discussed with CSCI about the needs of individuals they care for, and that primarily they offer support for those who need support with their physical care. However the individual may also need support with their safety and daily life through loss in their mental well being, these needs should also be addressed in the care plans. The manager advised the inspector that she is currently reviewing the care plans for the home as she feels they could be improved. Part of her plans includes encouraging the care staff to write ‘plans of care’, how they support individuals with daily life activities. There was evidence that both care staff and the nurses write daily notes about the support given to individuals, and these assist with the reviews of care, which were seen to happen regularly. The home had written policies and procedures available that were concerned with the management and administration of medication. Medicines were stored safely and appropriately in a locked and secure medicine trolley and also in a locked room where dressings were also kept in locked cupboards. A medical refrigerator was also used for medicines requiring special storage conditions. The temperature of the refrigerator was regularly checked to ensure that it was working effectively and a record was kept of the room temperature. Medicines were dispensed using a monitored dosage system supplied by the chemist and others are dispensed form their original containers and all of these were dated when they were opened/started. There were copies of the signatures of the nurses who dispensed medication readily available. Reference material and information about medicines was also readily available. Records examined included those concerned with the administration; ordering; receipt; and disposal of medicines, and all were accurate and up to date. There were controlled drugs being kept in the home at the time of the inspection and sedatives the home managed as if they were controlled drugs. A check of these was made and the balance of medication held was correct. Nurses and care assistants spoken to were aware of the contents of the care plans that were sampled and the assistance that the individuals concerned required, although a lot of the information was known due to amount of time the person had been cared for, not written. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 13 Comments from residents about the help that they received included the following: “They help me with everything I ask for even taking me to the toilet”. “The people look after me very well”. “The staff are lovely I have no complaints” “They help me get washed and dressed”. The inspector was able to observe staff interaction with residents and that staff promoted privacy and dignity. The inspector was able to speak with a relative who had visits regularly and who had joined their relative for lunch. They spoke highly of the home and said: “I would care for my relative at home if I could but I am able to visit regularly and we enjoy meals together. Its not home but they care and look after us both when I am here”. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers a variety of activities that are suitable for the needs of the residents. The home assists residents to maintain social contacts with the community and family. The meals are well balanced and residents generally have a choice about what they would like to eat and a choice of where they take their meals. EVIDENCE: The lounges, sitting areas and dinning room have been refurbished. The manager explained that most residents use one lounge as there are only 16 living at the home at present. There are a few who choose to spend their time in their room or who go to rest throughout the day. There are daily activities at the home supported by staff or from external visitors examples included: music and movement, massage and aromatherapy, games, quizzes and day trips, the local library visits and changes books, talking books, and spiritual services weekly. One resident attends a day centre a couple of days a week, which was attended before they came to live at the home. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 15 The home had several written policies that were concerned with the rights of residents. The manager is currently reviewing all policies at the home following it’s reopening in September 2006. The policies available at the home on the day of the inspection included: • Residents’ charter • Confidentiality • Access to personal files and case notes • Voting and the electoral register • Advocacy • Handling money and valuables • Self medication These referred to the right of residents to make their own choices, act independently and enjoy the same rights and freedoms as any person living in the community. The home’s manager said that the home did not take responsibility for the financial affairs of any residents. All the residents spoken with, who were able to comment, indicated that they were pleased to give the responsibility for such matters to relatives or their representatives. The home enables and encourages residents to furnish their own bedroom accommodation if they wanted to do so. Several residents spoken with said they had items of their own in their rooms and appreciated being able to personalise their bedroom accommodation so that it was “like home”. Items seen included tables, dressers, lights and television and audio equipment. The home had written policies and procedures about “Confidentiality” and “Access to Records” (see above). Sensitive information about residents was kept in the nurses office in locked filing cabinets. All residents spoken with said that the food provided by the home was good. Residents who were relatively active said they knew what the main meal of the day was because they could see the menu that was prominently displayed, or they could go and ask the cook. All commented that if they did not like the meal that was on the menu there were other options. However there was no choice displayed. • “They will always change it if you are not keen”. • “The food is good although there is no choice, I haven’t had to say I don’t like it yet”. They also confirmed that there three meals a day and could have snacks and drinks at other times. • “We always have a drink in the evenings and I have a biscuit with mine” • “I have a sandwich in the evening, cheese or ham”. • “There is always plenty of coffee all day”. • “We have our tea at about 5 to 5:50 and you can have something later if you want”. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 16 Information about the needs of service users with specific dietary requirements was readily available in the kitchen e.g. diabetic, soft, chopped up, etc. Pureed meals were provided with all their constituents prepared separately ensuring that their appearance was attractive. Some service users ate in their rooms and some in the home’s dining rooms. Staff were observed sensitively and appropriately providing help to those service users that needed assistance at meal times. Comments from residents about the food included the following: • “The food is very good”. • “The food is very good, very filling…” • “It’s very nice….”. One resident has additional fluid through a tube and it was seen that staff had full instructions as to how this was to be carried out for the individual and staff spoken with knew these instructions. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has established a sense of openness at the home so that relatives and residents can voice their concerns. EVIDENCE: There have been no complaints made since the last inspection to either the home or to the CSCI. Relatives and residents spoken with were aware of how to complain and said they felt comfortable in speaking with the manager or deputy about any issues. The deputy and staff were able to explain the homes procedure when receiving a complaint and the action that they would take. There have been no allegations regarding adult protection at the home. The manager undertakes training the staff in this area, and staff spoken with were aware of the whistle blowing policy and the training. Comments from residents about making complaints included the following: • “I would certainly complain if I was unhappy about something”. • “I would speak to one of the carers if I had a complaint”. • “If I was unhappy I would speak to the person in charge”. • “I would speak to the manager if I had a complaint as she is very approachable and lovely”. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 18 Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s accommodation was furnished and equipped satisfactorily for residents needs. There were systems and procedures in place to ensure the bedroom accommodation was both safe and comfortable. EVIDENCE: The home has been refurbished throughput and the environment was inspected in August 2006 before residents moved back to the home. On the ground floor of the home there is a large dining area and 2 lounges, which provide sufficient recreation space for residents, the grounds of the home are to be landscaped and appropriate fencing was being erected to protect service users. The recommendation from the inspector on that visit for the home undertake a risk assessment for the front of the home to ensure Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 20 safety for residents, has been actioned and the homes entrance area has decorative tiles and the amount of gravel has been lessened. The home provides 2 Bathrooms with assisted baths and WC’s, 2 shower rooms with WC and 1 standard bathroom with WC. In addition there are 4 WC’s situated around the home and these are close to communal facilities. The home has a passenger lift for access to all floors and there are also suitable call facilities in all rooms, bathrooms, WC’s and communal areas. There are aids, hoists and assisted toilet and bathing facilities and handrails are situated around the home. There were a total of 25 bedrooms for service users and these were broken down as follows: 13 single bedrooms, 8 single en-suite rooms, 1 double bedroom and 3 double rooms with ensuite facilities. All rooms met the National Minimum Standards with regard to floor space. Individual bedrooms contained all of the required furniture and fittings and these were all new and were of good quality, each room had a new fully adjustable bed and all rooms were comfortable. The home was centrally heated and service users could adjust the temperature in their own rooms. All hot water outlets were regulated and pipe work and radiators throughout the home were covered. The laundry at the home was being completed and the laundry floor and surfaces were impermeable. It was noted on this tour of the home that there is a ramp on the ground floor, which the staff have to step off sideways to enter the ground floor sluice, this could be hazardous and risk assessment is needed. There are also several steps in the laundry area that are not ‘highlighted’ and could also pose a hazard to staff. The home is decorated neutrally and the bathrooms are very plain. The manager says that she plans to look at the bathrooms and believes that the décor will change as the residents move into the home and begin to personalise their rooms. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Stands 27, 28, 29 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a suitable level of staffing and training programme that meets the resident’s needs. The home’s recruitment procedures for new staff were robust in the protection of vulnerable adults living in the home. EVIDENCE: The rota was seen for the home and there appeared to be adequate staffing for the needs of the residents. There is one nurse on during the day supported by care staff and one nurse at night also supported by care staff. In addition there are kitchen staff, a laundress and housekeeping staff. The pre inspection questionnaire returned by the home indicated that training was planned for the year for staff. This was seen at the inspection and staff confirmed that they had been asked what training they would like in addition to the mandatory training. A training programme for the year was seen to include mandatory training in food hygiene, fire and moving and handling. The home has plans to carry out training in areas such as dementia. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 22 The inspector was able to sample three staff records and found that they were detailed with the necessary checks taken to ensure staff are fit to work at the home. There are currently fours staff who have achieved their NVQ qualification of the 13 care staff that work at the home. The manager hopes that more will enrol later this year. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has a clear plan for the home, which appears to have been discussed with the staff, residents and owners. There are systems for consultation are to be put in place formally, evidence suggest that verbal views are acted upon. The home is well maintained and health and safety is promoted however there is a lack of risk assessment, which may place residents at risk. EVIDENCE: The manager worked at the home whilst it was in alternative accommodation during the refurbishment. She has recently been interviewed for registration Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 24 with CSCI. The manager has worked as a nurse for over 20 years and has spent many years working in the nursing and residential sector. It seems she is supported by staff who have been at the home for a while or have only been recruited since reopening. She stated that she is spending the first six months ‘getting the feel’ of the home and assessing the changes that are needed such as care plans, assessments and what support staff need. The manager stated that she has begun to carry out staff appraisals and hopes that they will be finished by March 2007; she plans to begin supervision also. Comments from people at the home included: * “She is very nice, understanding and very supportive………..she seems to know what she is talking about” (staff member). • “She brings me my paper most mornings, she is very nice” (resident). • “ Matron is wonderful” (resident). • “She is very nice” (resident) • “She is very nice, very friendly. You can call her any time if you need help, even if she is at home at weekends. She explains things so we can understand” (staff member). • “She is very good, a very good nurse. She is understanding of staff and if you have any problems you can talk to her in confidence” (staff member). • “She will help me if I need it. She is friendly.” (staff member) • “She is very caring. She goes out of her way if residents have a problem and see that they are looked after” (staff member). The manager has a system quality assurance for the home and plans to start this soon. The home does not look after any resident’s personal monies. The home had a range of written policies and procedures that were readily available in the home’s staff room that helped to inform staff working practice. They were reviewed and updated as necessary. Comments from staff about the policies and procedures included the following: “They are handy and they can be referred to if necessary”. Fire training records and tests were seen to have taken place regularly, the fire equipment company carried out tests on the day of the inspection. Staff receive adequate training on health and safety issues, as evident from the staff training plan, the inspector saw certificates for staff attending moving and handling training, food hygiene and Control Of Substances Harmful to Health. There are some risk assessments in place for the building however there are areas that need to be assessed that affect the safe working practices for staff. Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 25 Certificates showed the maintenance of services within the home were up to date Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Sch3 Requirement Timescale for action 31/03/07 2 OP38 13 (4) The registered person must ensure that all identified needs have a care plan that details support to be given by staff. The registered person must carry 31/03/07 out a risk assessment of the home paying particular attention to the ground floor sluice and laundry and take any action necessary. 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 Berehill House Nursing Home DS0000012205.V324452.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Berehill House Nursing Home DS0000012205.V324452.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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