Inspection on 30/10/06 for Berrishill Grove, 26

This inspection was carried out on 30th October 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berrishill Grove, 26 02/10/08

Berrishill Grove, 26 29/06/07

Berrishill Grove, 26 11/01/06

Berrishill Grove, 26 23/05/05

Berrishill Grove, 26 07/01/05

Berrishill Grove, 26 29/09/04

Berrishill Grove, 26 04/02/04

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

CARE HOME ADULTS 18-65 Berrishill Grove, 26 26 Berrishill Grove Red House Farm Whitley Bay Tyne And Wear NE25 9XU Lead Inspector Karena M Reed Key Unannounced Inspection 30th October 2006 13:00 Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 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 Berrishill Grove, 26 DS0000000367.V304387.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 Adults 18-65. 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. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berrishill Grove, 26 Address 26 Berrishill Grove Red House Farm Whitley Bay Tyne And Wear NE25 9XU 0191 2537212 F/P 0191 2537212 GM.E.NTAWNT.Berrishill@nhs.net 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) Northumberland, Tyne & Wear NHS Trust Karen Anne Wilkinson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation with board and care is provided at any one time shall not exceed 4 men or women 11th January 2006 Date of last inspection 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 lavatories. The house has a garden at the rear and an area for parking to the front. Berrishill Grove is part of Northgate and Prudhoe NHS Trust. Fees payable for living at the home at the time of inspection in November 2006 are £1169.66p weekly. Additional charges are payable for hairdressing, toiletries and eating out. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place over two and a half hours. A partial tour of the premises took place and a sample of records were inspected which included: The Statement of Purpose and service user guide, 4 care plans, the fire log, accident book, admission/discharge book, complaints record, 2 personal allowance records, 2 staff files, staff communication book, staff and resident meeting minutes. The manager, two support workers and 2 residents were spoken to at the time of inspection. A questionnaire was also completed by the home before the inspection to provide information. Comment cards were also sent to residents and other people involved with the home who may be able to comment about the running of the home. What the service does well: What has improved since the last inspection? The level of staff training continues to improve to equip staff to meet the needs of residents. All support staff have achieved National Vocational Qualifications at level 2. Efforts continue to be made to involve residents in all decision making in their lives and to offer choice to them. Communication is becoming more accessible to residents and ways being explored to use other than the written word. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has up to date information to provide to prospective residents about the home and its facilities to enable them to make an informed choice about where to live. The home collects enough information about the needs of residents before they move in to help ensure staff are aware of the amount of care and support needs of the resident as they settle in. Staff receive training to give them the knowledge and insight to help understand the needs of residents and to provide the necessary levels of care and support to individual residents. Contracts are available for each resident detailing the services they will receive from the home. EVIDENCE: The Home’s Statement of Purpose and service user guide were examined and they contained the necessary information as required by the Care Homes Regulations 2001 they had been reviewed in July 2006 to ensure they contained accurate up to date information. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 9 Records for the four residents when they were admitted to the home showed that an assessment of their care needs had been carried out before their admission. The resident and relevant people who knew the person were involved in the initial assessment. This information and the care manager’s assessment of the resident’s care needs were used to ensure all the needs of the resident could be met by staff. The records contained a range of information. The pre inspection questionnaire showed staff receive training so that they know how to meet the specialist needs of the residents. Staff have received Fire Training, Moving & Assisting, Learning Disability Awareness as part of new staff induction. Working with behaviour that may be challenging, First Aid, Safe Handling of Medication and National Vocational Qualifications & Protection of Vulnerable Adults training. Future training planned includes conflict resolution, First Aid and risk assessment. Contracts were available on each residents’ file they were detailed and outlined terms and conditions for living at the home. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are excellent arrangements in place to ensure that residents’ health and social care needs are met. There is a system of reviewing the changing care needs of residents. Residents are well supported by staff and care plans reflect the amount of care and support that staff are providing to residents. Residents are encouraged to communicate and make their views known. Staff support residents to take risks as part of independent living. Information about residents is handled appropriately, and their confidences are kept. EVIDENCE: There are detailed assessments in the residents’ care plans. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 11 Personal support needs are well documented and give clear instructions to staff on how to support people in tasks such as washing, bathing, dressing, communicating and carrying out any assessed tasks to help promote the independence of the person. Residents care records showed that they have access to external health care services. GPs and Community Nurses were regularly consulted for advice and treatment. Records show residents are assisted to access chiropody, dental and optical services at least annually or as often as required. Residents are asked individually and consulted about decisions involving themselves and the running of the home. The home promotes the independence of the resident and provides whatever levels of supports are required and to take risks in order to live a more fulfilled lifestyle. Up to date risk assessments were in place in residents care records. Residents care records all contained statements of confidentiality to remind staff what information could or could not be disclosed about residents. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in age, peer and culturally appropriate activities. Residents are part of the local community. Residents enjoy appropriate leisure activities. Residents are encouraged to have appropriate personal, family and sexual relationships. Residents’ rights and responsibilities are recognised in their daily lives. Residents are offered a healthy diet. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 13 EVIDENCE: Conversation and observation of residents and staff showed staff support residents to acquire skills and become more self sufficient in aspects of every day living. Residents may attend day care services or enjoy individual therapeutic activities within the community. Residents all pursue their own individual hobbies and interests eg trampolining, cooking, Snoezellen, walking, swimming, aromatherapy, gardening, bowling, cinema and theatre trips. Residents have also holidayed in the Lake District and Spain. They also enjoy meals out, socializing with residents of other homes, visiting the local pub, shopping and some attend a weekly evening club. Within the home residents bedrooms are equipped with their own televisions, music centres, books and whatever is of interest to the resident. Residents care plans and case records detail any family involvement. Conversation with staff also provided evidence that residents are encouraged to maintain contact with family and friends, staff providing the necessary levels of support for them to do so. Residents are asked individually daily what they wish to eat. A light snack is available at lunch times and a cooked meal is served in the evening. The menus are revised with the help of the residents. Residents may often eat out. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents do receive support in the way they prefer and require. There are arrangements in place to ensure that service users’ health care needs are met. Systems are in place for residents to retain and administer their own medication where appropriate. EVIDENCE: Four care plans and case records were inspected. The daily records detailed the care and support required for different needs. They reflected the changing needs of service users due to becoming older or due to ill health. The care plans accurately recorded the needs and the care and support provided by staff. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 15 Records showed when residents had seen health professionals eg doctors, community nurses, etc. Records also showed when residents had seen opticians and dentists. Staff receive training before they administer medication to residents. A system is in place to oversee the medication of residents if they should retain and administer their own medication. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is out of date which could mean that issues are not raised outside of the home. Residents are protected from abuse. EVIDENCE: There is a complaints procedure. If complainants are not happy with the homes investigation and response however it does not provide details of how to contact CSCI to make a complaint. The home keeps a record of complaints. As part of staff induction they receive training about the rights of people with learning disabilities. Staff have received training about Protection of Vulnerable Adults and Prevention of Abuse. Staff are to receive refresher training about working with behaviour that may be challenging. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment however the premises are showing signs of wear and tear. Service users’ bathrooms do not meet individual needs. There is a quite a good standard of hygiene around the home. EVIDENCE: There is a very limited programme of redecoration and improvement around the home. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 18 The home is quite clean and well furnished however it is not well maintained and several areas are in need of decoration and maintenance. The hallway has several nail holes in the walls, leaving the walls damaged and marked. The doorways and hallway are chipped and marked due to wheel chairs banging into walls. One bedroom is in need of decoration as walls are marked. The flooring to the shower room is worn, marked and uneven. The dining room carpet is marked and smells, despite washing, due to food frequently falling or being spilt from the table. The décor in the kitchen is worn especially around the hatch area leading into the dining room. The utility room décor is dirty and marked. The flooring in the kitchen is damaged and worn and presents a hazard to health and safety. The walls surrounding the doorframe in the office are badly cracked due to the door slamming heavily during fire drills. The driveway leading to the front door of the home is uneven and difficult to walk on, as it is gravel it makes it very difficult to push or self propel a wheelchair. Several assessments have been carried out for the use of the current bath. Evidence is available to prove that it does not meet the needs of two residents who have difficulty getting in and out of it due to their poor mobility and high levels of physical dependency. All residents bedroom are well furnished and personalized according to the interests of the individual. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 19 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met during the week by the numbers and skill mix of staff. Systems are in place to ensure residents are in safe hands. Residents are protected by the home’s recruitment policy and practices. Staff are trained to meet the care needs of residents EVIDENCE: Examination of staff rotas and discussion with the person in charge and members of the staff team showed that the numbers of staff are as follows: 8.00am- 6.00pm 6.00pm-8.00pm Berrishill Grove, 26 2 support staff and two enablers. 2 support staff DS0000000367.V304387.R01.S.doc Version 5.2 Page 20 8.00 pm-8. 00am following day 1 sleep in staff member. These numbers include the team leader. The home provides two support workers and two enablers to work with residents during the day. Staffing levels at weekends usually provide only two members of staff when all the residents are in the house eg out of eight weekends there are only three weekends when three members of staff are available. This reduces the opportunities for residents to go out into the community and also reduces their choice as everyone would either have to stay in or go out due to only two members of staff being available. No ancillary staff are provided staff members carry out cooking and cleaning. Staffing files for the staff employed at the home were examined at Head Quarters and showed the necessary checks are being carried out prior to the workers being appointed. CRB checks are carried out before a person is appointed. Staffing files did not provide evidence of the identity of the worker including a photograph. Staffing files did not provide evidence of the qualifications of appointed workers. Staff stated that they enjoyed working in the home and were observed to be kind, caring and respectful to residents. Staff receive LDAF Learning Disability Award Framework as part of their induction. Staff and their records showed that they also receive advice and /or training in other areas. Staff have received training in emergency First Aid, person centred care planning, challenging behaviour, Medication and Protection of Vulnerable adults. Staff receive supervision every two months from the manager. A system is in place for managers’ of the Organization to receive regular supervision from a member of the senior management team. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 21 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a very well run home. Residents and staff benefit from the ethos, leadership and management approach of the home. There is a regular system to review the quality of care provided by the home. There is a high standard of record keeping. The health, safety and welfare of residents are promoted and protected. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 22 EVIDENCE: The person in charge has completed the Registered Manager’s award. Discussion and observation maintain that she puts the needs of the residents first and promotes an ethos amongst staff of involving staff and residents in decision making within the home. Residents living at the home have lived there for several years and the staff advocate for residents where necessary as well as using external advocates to speak up for them. Documents detailing fire safety, risk assessments in the environment, water temperatures, financial records and statutory records were all up to date. Staff training relating to health and safety was up to date and training being planned to renew any that required updating such as first aid, medication training. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 23 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. 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x 3 3 x Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 2(d) 23 2(b) 2 3. YA22 YA27 To repair damaged walls. 22 7(a)(b) The complaints procedure must be updated to include details of how to complain to CSCI. 23 A specialist bath must be provided to meet the reassessed needs of the two residents. This requirement remains outstanding. 4. YA33 18 Staffing levels at weekends must be reviewed. 31/01/07 30/11/06 28/02/07 Requirement Timescale for action To provide a programme of re decoration for the home and replace identified floor coverings. 30/11/06 5 YA34 7,9,19 Schedule 2 1,2,3,4 This requirement remains outstanding. Staffing files to contain proof of 30/03/07 a persons’ identity including their photograph and evidence of any qualifications. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 25 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 YA24 Good Practice Recommendations To resurface the driveway. Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Berrishill Grove, 26 DS0000000367.V304387.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!