This inspection was carried out on 23rd May 2005.
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.
CARE HOME ADULTS 18-65 26 Berrishill Grove Red House Farm Whitley Bay Tyne & Wear NE25 9XU
Lead Inspector Janine Smith Unannounced 23 May 2005 10:30. 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. 26 Berrishill Grove Version 1.10 Page 3 SERVICE INFORMATION
Name of service Berrishill Grove, 26 Address Red House Farm Whitley Bay Tyne & Wear NE25 9XU 0191 253 7212 0191 253 7212 communityhome@berrishillgrove.fsworld.co.uk Northgate & Prudhoe NHS Trust 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) Karen Anne Wilkinson CRH 4 Category(ies) of LD Learning disability (4) registration, with number of places 26 Berrishill Grove Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 7/1/05 Brief Description of the Service: 26 Berrishill Grove provides residential care for four adults with a learning disability. Nursing care is not provided. The home is a modern, spacious bungalow on a quiet housing estate in Monkseaton. There are good road and transport links and the house is close to local shops and amenities. Each resident has a single bedroom and there is a bathroom and toilets. The house has a good sized garden at the rear and an area for parking to the front. Berrishill Grove is part of Northgate and Prudhoe NHS Trust. 26 Berrishill Grove Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6 ½ hours. A partial tour of the premises took place and a sample of care records were inspected as well as other records. All four of the residents and three of the staff team were spoken to. What the service does well: What has improved since the last inspection?
Four requirements made following the last inspection have all been acted upon. Re-decoration has been carried out and the house provides good quality homely accommodation to its residents. 26 Berrishill Grove 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. 26 Berrishill Grove 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 26 Berrishill Grove 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) As there has been no new admissions, these standards were not assessed on this occasion. EVIDENCE: 26 Berrishill Grove 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, 7 and 9. The content and presentation of the care plans was good which helps ensure that the staff are well informed about the needs of residents living in the home. Residents’ rights to make decisions about their day-to-day lives are respected by the staff team, which ensures that their lives in the home are fulfilling and satisfying. EVIDENCE: During this inspection, two care plans were inspected. They contained a great deal of detailed information about the personal, social and health care needs of the residents. Members of the staff team on duty were well informed about the individual needs of the residents. Risk assessments are carried out and are aimed at ensuring residents are supported to participate in fulfilling activities. The staff were observed to consult and communicate well with residents throughout the day.
26 Berrishill Grove 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, 15, 16 and 17. Links with the community are good and these support and enrich residents’ social lives. EVIDENCE: Discussion with staff and examination of records showed that the residents participate in a range of activities in the community, such as sports, swimming, aromatherapy, cookery classes. Other courses at a local college are also being tried out. They enjoy being part of the local community and regularly take walks and use coffee shops, shopping centres, pubs and the cinema. Advocates are obtained for residents who have no close family. A nutritious menu plan is in place and residents receive appropriate support at mealtimes. Observations made and discussion with staff confirmed that residents are offered choices at all meals. Residents help with the shopping for meals.
26 Berrishill Grove Version 1.10 Page 11 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) 18, 19 and 20. The health needs of residents are well met, other than more thorough monitoring of their weight is needed and to ensure that they are offered eye tests at appropriate intervals. EVIDENCE: Inspection of the care records showed that residents are provided with the support they need with personal and health care needs. However, whilst residents were being weighed regularly, there was a lack of evidence that consistent patterns of weight loss and low body weight were identified as a concern. It was also difficult to establish from the records whether residents were offered eye tests at appropriate intervals. A random sample of medication records and the system for storage and handling medication was looked at and found to be appropriate. 26 Berrishill Grove Version 1.10 Page 12 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 has a satisfactory complaints system and training is to be arranged in adult protection, which helps to protect residents from abuse. EVIDENCE: A complaints procedure is in place. The Manager confirmed that arrangements are being made to provide Adult Protection Training to all of the staff team. 26 Berrishill Grove Version 1.10 Page 13 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, 25, 26, 27, 28 and 30. The house is well maintained and provides residents with an attractive, spacious and homely place to live. EVIDENCE: Each resident has their own bedroom and there are shared bathing and washing facilities. The house has a pleasant lounge, dining room and conservatory. The garden is spacious and not overlooked. Residents were seen to move around the house as they wished. Since the last inspection redecoration has been carried out. All areas were seen to be clean and well kept. 26 Berrishill Grove Version 1.10 Page 14 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) 33. Good staffing levels are maintained in the home which means the staff are able to work effectively with residents. EVIDENCE: On the day of inspection there were three care staff on duty. Through the night there is one waking night carer. The last inspection identified a need to review weekend staffing levels to ensure residents had opportunities to get out and about. This has been done. Whilst sometimes there may be only two staff on Sundays, the staff on duty said that this did not present any problems in supporting residents to go out locally. The members of staff on duty during this inspection were experienced and communicated well with residents. There was a relaxed friendly atmosphere in the home. 26 Berrishill Grove Version 1.10 Page 15 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) These standards were not examined during this inspection. No health and safety concerns were identified during the visit. EVIDENCE: 26 Berrishill Grove Version 1.10 Page 16 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 Score x x x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Score 3 2 3 Standard No 37 38 39 40 41 42 43 Score x x x x x x x
Page 17 26 Berrishill Grove Version 1.10 21 x 26 Berrishill Grove Version 1.10 Page 18 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 19 Regulation 12(1) Requirement Ensure that appropriate action is taken where residents are losing weight. Ensure that residents are offered eye tests at appropriate intervals. Timescale for action 31st July 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 33 Good Practice Recommendations The rota should include the full name and designation of staff, as well as a key to the codes used. 26 Berrishill Grove Version 1.10 Page 19 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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