Inspection on 16/02/06 for Berengrove Park Nursing Home

This inspection was carried out on 16th February 2006.

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 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

Berengrove Park Nursing Home 22/10/08

Berengrove Park Nursing Home 11/12/06

Berengrove Park Nursing Home 24/06/05

Berengrove Park Nursing Home 31/01/05

Berengrove Park Nursing Home 24/09/04

Berengrove Park Nursing Home 22/01/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Berengrove Park Nursing Home 43 - 45 Park Avenue Gillingham Kent ME7 4AH Lead Inspector Lucy Ansell Announced Inspection 16th February 2006 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 Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Berengrove Park Nursing Home Address 43 - 45 Park Avenue Gillingham Kent ME7 4AH 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) 01634 850411 01634 840046 Berengrove Limited Carole Frances Godden Care Home 36 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (24) of places Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to be aged 60 years or over. Date of last inspection 24th June 2005 Brief Description of the Service: Berengrove Park Nursing Home is home to 36 Older People who mainly have nursing and high care needs. The home also has 12 beds designated for dementia care. The home itself is a large older property, which means a lot of the bedrooms are of a large size. There are a high number of shared rooms in this home but the owner has added another five en-suite bedrooms to reduce the shared rooms. The home has a small garden to the rear and to the side of the property, which can be accessed by service users, and there is off road parking to the side of the home. The home is opposite a large park, which during the summer months is very pretty and is a nice area to walk in. The home is situated within walking distance of a main bus route and there is main line railways station approximately a mile away. Gillingham also has a High Street with many main High Street stores, and is not far from the Historic Chatham Dockyard. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection took place on the 16th February 2006 by one inspector Lucy Ansell. The Inspector agreed and explained the inspection process with the Registered Owner and the manager. Documentation and records were read, including care plans. Time was spent reviewing a sample of written policies and procedures, looking at care plans and records kept within the home. A tour of premises was undertaken. The focus of the inspection was to assess the Home in accordance to the National Minimum Standards for older persons and to seek resident’s and representatives views of the home. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. Some Standards were not inspected in full and the last report should be read in conjunction to obtain a full picture. What the service does well: The plans of care indicated in detail the care required to meet the individual needs of the residents. The care plans seen were of a high quality. It was noted that staff regularly review all aspects of the care plan recording outcomes and making changes, as required, daily logs were informative and comprehensive. On inspecting the home it was apparent that staff maintain a high level of cleanliness and a high level of decorative order was maintained throughout the home. The home have shown a high commitment to giving the staff sufficient skills and knowledge to ensure the service users are well cared for. The home has achieved 65 of their staff having gained the NVQ level 2 in care or above. The home provides a comprehensive induction package for all new staff. The home has a comprehensive and robust policy and procedure on recruitment that they follow meticulously. The information retained by the home on staff files is kept well maintained. There was good feedback from the service users and relatives and the home was recognised as being on the whole able to provide an excellent service. The manager and her staff are approachable and the home well managed. Service users were complimentary about the staff and about the way in which their service was provided. Comments received included ”shown immense kindness and patience” “treated with the utmost kindness and respect”. The food was also praised as “excellent and very tasty”. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 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 the following standard(s): 1,3,4 Prospective service users and their relatives have access to the information they require to make an informed choice about the home. There is a system of pre assessment at the home that enables staff to assess the needs of residents satisfactorily and assure that these will be met at the home. EVIDENCE: The home reviews and revises its statement of purpose and service users guide every six months. It is clear and concise with all relevant information included. Residents are admitted following a full assessment by the homes manager or one of the registered nurses. The information gathered forms part of the overall care plan. The pre-assessment paperwork seen was very detailed and also had a good front sheet included with care manager details and the place where the interview was conducted. However a good practice recommendation was made to provide evidence of where the information was obtained from e.g. family member or social workers care plan, hospital cardex. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 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 the following standard(s): 7,8,11 Residents benefit from a high standard of care planning and their health care needs are fully met. All residents would benefit from being consulted, regarding their wishes concerning terminal care and arrangements after death. EVIDENCE: Four residents care plans were looked at. These were detailed records, which contained good personal and health care recording. The health needs of residents are well met with evidence of good multi-disciplinary working taking place on a regular basis. The risk assessments were clear and concise, and a family member and one of the staff team signed assessment forms around mobility or restraint. The home has in the file a checklist for questions to ask and checks to be made on admission. where a resident will be sharing a room complete agreement is gained from both residents. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 10 Evidence was seen that reviews are taking place regularly. The manager has in place a system to monitor all care plans after the staff have completed their reviews. The home operates a key worker system where residents have an identified staff member. The staff are now recording enough detail in the daily report, it was also noted that when events and care delivery occurs throughout the day a detailed and comprehensive record is kept with good use of times. The staff still needs to be aware that they are leaving gaps and spaces between each recording. This could mean that at a later date something could be added to their notes, so to avoid this sign after the recording and draw a line to the end. The home promotes and maintains residents health through supporting and facilitating medical appointments as required. The home is well able to manage residents with pressure areas with treatment and has a tissue viability link nurse. The home has good links with other professionals and the home can offer a choice of G.Ps from the many surgeries situated locally. A good practice recommendation was made to ensure that evidence is seen of crossreferencing to support good practice. e.g. if weight is low and referral made to dietician to write this on weight chart and daily notes and health records so clearly evidenced what they are doing. Residents/relatives are consulted regarding their wishes concerning terminal care and arrangements after death during the pre-assessment stage and if this is known recorded on their care plans. However the home has a duty to follow this up with a letter at a later date if not known or still discussing this issue to ensure it is recorded on their file. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 13 Residents benefit from maintained contact with family/friends and local community as they wish. EVIDENCE: Evidence was seen of visitors coming into the house all day with no restrictions imposed on these visits. Residents could choose to see their guest in private in their own rooms or one of the quieter lounges, staff would assist with this. The residents are also able to choose whom they do not want to see. The homes’ involvement with the local community is, contact with local church visits and school visits as appropriate. The staff also takes out residents to the local park as the weather and residents health permits. The home is also looking to organise shopping trips into the local area, trips out when the warmer weather arrives. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16,17,18 The residents and their relatives benefit from having access to the home’s complaints procedure. The residents benefit from all staff knowing how to report appropriately any possible abuse, and what immediate action to be taken to protect residents. Resident’s legal rights are protected. EVIDENCE: The home has a clear step-by-step procedure that meets the requirement of the regulations. The complaints procedure was displayed within the home and evidence was seen of it included in the statement of purpose and service user guide. Evidence was seen of a copy of the complaints form. The home has received no complaints since the last inspection; two concerns that were brought to the owners’ attention were looked at and resolved to everyone’s satisfaction. The residents at the home were all able if they wished to participate in the last elections. Many residents used postal votes and family could take residents up to the polling station, which is very close by. The home has access to an available advocacy service if no family or care manager is available to fulfil this role. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 13 The home ensures the residents are safeguarded from any abuse, neglect or harm by robust policies for the home. The homes nominated Adult abuse trainer gives training for all staff at induction, the staff then attend courses in the Local Authorities protocols on Adult Protection, as well as having a copy of the updated policy on file. Staffs when questioned were able to give comprehensive replies to what they would do in case of suspected harm to a resident. The home has a whistle blowing policy and a policy on gifts and gratuities. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19-26 Residents benefit from living in a safe, well maintained, clean and homely environment in which there are good standards of décor, furnishings and fittings. EVIDENCE: The home’s location and layout is suitable for its stated purpose; it has been visited by the fire officer and recently by environmental health and had met all their requirements. The home has three communal lounges spread across the building, split into one of which is a quiet room, another for viewing the television or activities area. The home has a small private phone room, dining area, but mainly residents eat in their rooms. Several residents spoken to commented “On the welcoming feeling of the home”, all residents when questioned enjoyed feeling part of a busy home. Five rooms in the new wing have ensuite toilet facilities and rooms where these are not included a suitable bathroom/toilet is located nearby. The home has sufficient toilet and bathroom facilities for the number of service users. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 15 Bedrooms seen had all been personalised by the service users. The rooms were all clean and well decorated. Bedrooms have sufficient space to accommodate the required furniture. The home has high standards of cleanliness and cleaning staff has rotas of which rooms to deep clean daily and only occasional odours were detected in the house. The home has two separate laundry room, one downstairs, which did not, met infection control requirements as walls not impermeable and finishes readily cleanable. The kitchen was viewed and this was well maintained. The home has two sluice rooms and hand-washing facilities are prominently sited and the provision of protective clothing was clearly seen. The home has a 6 monthly contract for servicing for the hoists and parker baths. The maintenance man checks and services all the wheel chairs and recorded evidence is kept of this. Call systems were seen in all the rooms and provided in communal areas. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 Residents’ needs are met by sufficient number of staff who are motivated and enthusiastic. Residents benefit from the homes robust recruitment policies and procedures. EVIDENCE: Staff rotas were seen and evidenced that staffing was suitable to provide appropriate shift cover. On the day of inspection one extra carer was provided in case any staff went off sick. The home does use agency staff and always uses the same agency with reliable care staff to call on. The staff working in the home are encouraged to have an NVQ, from domestic to care staff. There are seven staff who have NVQ 2 or 3 and several staff taking an NVQ who are due to complete early this year. 2 qualified nurses and 5 carers staff the home on the morning shift, then in the afternoons 2 qualified nurse and 4 carers and in the evenings 3 waking staff 1 qualified. The home also employs a cook, Handyman, activity co-ordinator and several domestic staff for cleaning and laundry room. A number of staff files were sampled, which included all types of staff, who had been at the home for varying lengths of time. The files seen contained all the correct information. Evidence was seen of clear colour photos of staff, and several different types of identification. The reference request asks managers to confirm dates that an employee worked for the said firm. Good practice was seen of a clear front sheet recording dates when asking for any references or Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 17 CRBs and then consequently when received. Evidence was seen of interview notes on one of the files for a new member of staff. All staff had enhanced CRB disclosures. Evidence was seen that checks are being carried out to see that trained staff possessed the qualifications needed to fulfil their respective roles and were registered with their regulatory bodies. There are robust written procedures in place for recruitment and selection of staff. The files were clear and well laid out containing all the required information and exceeding the required standard. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,38 The residents benefit from having a well supported and well led staff team who are appropriately supervised. The resident’s best interests are safeguarded by the homes policies and procedure and their health, safety and welfare are promoted and protected. EVIDENCE: The residents benefit from the management approach of the home and an open and inclusive atmosphere is created. The processes of managing and running the home are open and transparent. The owner and manager work well together communicating a clear sense of direction, and with defined roles and responsibilities between them they create an excellently managed home. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 19 The home has suitable accounting and financial procedures in place that evidence financial viability. The home is financially viable and finances are spent on improvements as are needed. A copy of the homes development and financial plan was seen. Insurance cover for the home was seen. The homes exclusive business plan is of an excellent standard and contains a detailed cash flow forecast. Records are kept of all transactions entered into by the manager or owner. The manager ensures as far as is possible the health safety and welfare of the residents and staff. Their moving and handling training is up to date, they are current with fire safety equipment and procedures and testing, evidence seen to support this. They hold current first aid certificates, food hygiene and infection control training, which is current, Environmental health visited last month and all compliances have been completed. The home has safe storage for hazardous substances and COSHH sheets with risk analysis have been obtained. The home has fitted a valve to regulate the water temperatures and checks for Legionella were evidenced, and risk assessments for the property have been carried out. The manager and owner ensure compliance with all relevant legislation. Evidence was seen of the policies and procedures for maintaining a safe working environment including induction training on safe working practices. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 20 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 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 4 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 4 x 4 x x x 4 Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 21 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 OP11 Regulation 17(1)(a) Requirement Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. Timescale for action 30/08/06 2 OP26 16(j) 30/08/06 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 OP3 Good Practice Recommendations The home to ensure all pre-assessment forms are dated and signed and the place where the interview was conducted and where the information has come from, is clearly put on the form To ensure that all evidence is able to be cross-referenced DS0000026149.V273818.R01.S.doc Version 5.0 Page 22 2 OP7 Berengrove Park Nursing Home 3 OP7 and it is clearly stated to show what has been already completed. The daily recordings need to ensure that no gaps or lines are left between each record of events. Berengrove Park Nursing Home DS0000026149.V273818.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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