This inspection was carried out on 3rd May 2005.
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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Berehill House Nursing Home Jobsons Close Newbury Road Whitchurch Hampshire RG28 7DX Lead Inspector
Feargal Gallen Unannounced 3 May 2005 - 10:30am 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 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 H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Berehill House Nursing Home Address Jobsons Close Newbury Road Whitchurch Hampshire RG29 7DX 01256 893087 01256 896795 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) Hestia Care Limited Mrs Veronica Sharon Bovill CRH 30 Category(ies) of DE(E) - Dementia - over 65 (8) registration, with number OP - Old Age (30) of places Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Ten service users in the receipt of personal care only can be admitted into the home. Date of last inspection 29 January 2005 Brief Description of the Service: Berehill is a home for service users in the category of older persons and older persons dementia. The home is located close to a small village. The building is a large older detached property with accommodation over three floors that is accessed by using a shaft or stair lift. The lounges and dining room are located on the ground floor. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over five hours and the manager was present for the majority of the process. The provider was also in attendance for some of the inspection. Care and staff files were looked at. Four members of staff, three residents and one family member were spoken to. What the service does well: What has improved since the last inspection? What they could do better:
Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 6 The home will benefit from further redecoration of the communal areas as planned. The gathering of references should be from appropriate persons or checked after receiving them to confirm contents are accurate. More could be done to involve the resident’s in the running of the home. 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. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Resident’s needs are assessed prior to admission to the home. EVIDENCE: The four resident’s files that were looked at all contained a pre-admission assessment of needs. The form is divided up into different sections and allows for written comment from the assessor on the particular need assessed. The manager or the deputy manager, carry out all the assessments. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8 and 10 The home is currently meeting the health care needs of the residents. The resident’s are respected and are given privacy. EVIDENCE: Each of the resident’s once admitted to the home if are registered with a local G.P. surgery. This gives access to the range of services available under the NHS. The dentist and optician visit the home at regular intervals. Changes in resident’s health care needs are documented in the daily notes and what actions have been taken. The resident’s and family spoken to felt they were treated with respect and given privacy. Staff were observed knocking on doors before entering rooms and speaking to then residents in a manner suitable to their needs. Medical treatments take place in residents bedrooms. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 None of these areas were inspected on this occasion. EVIDENCE: Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home will act upon any complaints it may receive. EVIDENCE: During the inspection the complaint log book was looked at and no complaints have been recorded for over two years. There is place a complaints policy and this is displayed in various parts of the home as well as the service user guide. The residents and family spoken to said if they had a complaint they would speak to the manager directly about their concerns. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 Residents live in a safe environment although the home is currently in need of redecoration in the communal areas. EVIDENCE: During the tour of the home it was noted that the environment is in need of redecoration. Some areas have already received attention but the majority of the home still requires work to make it a well-maintained place to live. There is a plan to carry out this work when building work on another site owned by the provider is complete. This is due to finish in the next few months. Although there is work to be done in the home it was very clean and had no unpleasant odours present on the day of the inspection. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Residents are supported by a well maintained and skilled staff. Recruitment practices do not always safe guard residents. EVIDENCE: The duty rota for the previous four weeks was looked at and staffing levels appear to be meeting the needs of the residents. There is a registered nurse on duty at all times and is supported by a team of care assistants with different levels of skill and experience. Residents feel that staffing levels are a little low at times. This was discussed with the manager who stated levels remain constant even when fewer residents in the home. Files for three members of staff were looked at. One of the employees had a reference supplied by a senior carer rather than the manager. References should be supplied by the manager of a previous employment. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The resident have very little input into how the home is run. EVIDENCE: There is a resident’s survey that is completed on behalf of the resident by members of staff who ask the questions to the residents then write down or tick the reply. There are no residents meetings or forums but there are family/carer meetings held regularly. Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x x x x Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 16 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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 Good Practice Recommendations Berehill House Nursing Home H54 S12205 Berehill V224598 030505.doc Version 1.30 Page 17 Commission for Social Care Inspection 4 Floor, Overline House Blechynden Terrace Southampton Hampshire SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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