Inspection on 18/07/05 for Berry Hill Care Home

This inspection was carried out on 18th July 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.

Other inspections for this house

Berry Hill Care Home 20/06/07

Berry Hill Care Home 26/06/06

Berry Hill Care Home 24/11/05

Berry Hill Care Home 15/11/04

Berry Hill Care Home 25/05/04

Berry Hill Care Home 07/01/04

Berry Hill Care Home 11/12/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Berry Hill Care Home Berry Hill Lane Mansfield Nottinghamshire NG18 4JR Lead Inspector Jayne Hilton Unannounced 18 July 2005, 7.00am th 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 and 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. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Berry Hill Care Home Address Berry Hill Lane Mansfield Nottinghamshire NG18 4JR 01623 421211 01623 428864 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) Southern Cross Health Care Acting manager Dorothy Turton Care Home with Nursing 63 Category(ies) of 63 - OP - Old Age registration, with number 1 - TI - Terminally Ill of places Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15/11/04 Brief Description of the Service: Berry Hill Park Care Centre is a 63-bedded care home providing nursing and residential care, owned by Southern Cross Healthcare . It is a two-storey building within extensive grounds. The building is situated on a main road with access to public transport and a direct bus route to Mansfield, which is three miles away.The accommodation was originally divided into two wings but is now regarded as one whole unit. Accommodation consists of a total of 48 single rooms, all ensuite except one and eight double rooms, all ensuite. Staffing provision is primarily by qualified nurses and care assistants for nursing service usersand senior carers and care assistants for personal care only service users. The acting care manager is responsible for the whole complex.There is a car parking facility at the front of the home and an enclosed, fenced garden at the rear, which overlooks a large field, used by the general public. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 18th July 2005 at 7.30am by Jayne Hilton and Lee West. The inspection focus was mainly on the standards not inspected at the previous visit and to follow up on the requirements set. A new manager has been in post since the previous inspection and the home was subject to a take over by Southern Cross in March 2005. Therefore some of the previous requirements have not been completely finalised and the inspectors have taken this into consideration throughout the assessment process. Nine service users were spoken to in total, five in detail and two relatives. Three staff and the manager also contributed to the inspection process. Care records were examined in detail for five service users and associated records, such as the accident records, staff rotas, complaints records and resident meeting minutes. And service users financial records. The inspection process was seven hours in duration. The acting manager has submitted an application for registration with the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 6 The requirements set at the last inspection have been met or almost fully addressed. A shower room is currently being fitted to meet the bathing preferences of individuals. Social profiles have been devised and life story books are underway. The drainage problems in the car park have been resolved and the car parking facilities overall have been made safer. 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. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 Prospective service users have the information they need to make an informed choice, however service users would benefit from an individual copy of the service user guide and a copy of their contracts in their personal files. Service users needs are assessed and clearly state that their needs are met. EVIDENCE: The statement of purpose and service user guide was displayed in the front entrance, however there was no evidence that service users had been issued with individual copies of the service user guide. A relative confirmed that a brochure was issued a few years ago. The statement of purpose was not inspected at this inspection and will need to be assessed as to whether it meets with Schedule 1 of the regulation at the next visit. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 9 The previous inspection report noted that service user contracts were held within service users care files and therefore accessible for service users. At this inspection these were not available within the care files and therefore not inspected. It is good practice that a copy of the service users contract, be held within the care file. The care records for five service users were examined in detail. Pre-admission assessments are completed before service users are admitted to the home. The deputy manager or acting home manager visits the prospective resident in their previous environment and discusses the needs with the resident and his/her representative. An appropriate assessment tool is used to assess nursing input and personal needs, however it was noted that foot care is not included in the document, neither was it documented within any of the care plans examined. A couple of assessments were not as detailed as the others regarding medical history and medication details. If a Social Service Community Care Assessment is available, this will form the basis of the further assessment by the care manager and is used as the foundation of the care plans, as evidenced in care plans seen. Service users and relatives spoken with reported that overall they felt their needs were being met and praised the staff. There was evidence of professional input regarding physiotherapy and specialist equipment being obtained as needed. One service user had been provided with a longer cable for the call alarm to meet her particular needs and wishes. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9,10, 11 Care plans are in place and progress has clearly been made. Service users would benefit from improved record keeping and evaluation of care plans. The health care needs of service users are generally met but they would benefit from improved documentation, particularly in relation to nutritional needs and routine health checks and to ensure these needs are not overlooked. Service users privacy and dignity is generally respected, but again service users quality of life could be improved by better practices in this area. The wishes of service users for the end of their life were obtained wherever possible. EVIDENCE: Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 11 The care plans examined for the service users case-tracked show fairly detailed completion and are in a good, easy to read format, however gaps were noted and the inspectors identified several issues that had not been addressed by the implementation of care plans for example for dealing with challenging or aggressive behaviour. Some care plans were better than others, most contained detailed instructions for staff in how to carry out the plan of care and were personalised to the individual’s choices and wishes. Social profiles are included and it was reported that further work is being carried out in conjunction with the activities co-ordinator to develop these further. More residents and/or their representatives are involved in the creation and reviews of their care plans. The manager says that improvement and updating of care plans is ongoing and realises that there are some care plans, which are still in need of comprehensive completion. The inspector has evidenced that the staff are making efforts to complete these and that service users and their relatives are constantly being approached to be involved. Most of the care plans examined contain relevant information on the nursing interventions needed to meet the needs of the individual residents, care is needed however to ensure that these are updated as needed. Not all of the care plans seen, were up to date with monthly reviews, some not being reviewed since 20/11/04. Most had not been reviewed since April 2005. Personal care is documented on a specific chart, however there was noted gaps and as there were complaints documented and comments made on the day of the inspection that service users have been left unattended in bed, and taking into consideration that there were some occasional gaps in daily reporting within the care notes the manager is required to ensure that systems are improved, to ensure that each and every service users needs are met and documented on a daily basis. There was evidence within other records that chiropody services were available, however the care plan records did not reflect this. It is recommended that a record sheet is introduced, to be kept within the care file for all health checks and treatments. There is a key worker system in place and care plans are evaluated by a weekly diary. Most of the weekly evaluations had not recorded all events and issues found in other records, which identified, that the process of evaluation and cross- referencing was not being appropriately practiced. Risk assessments were in place for mobility, nutrition, and tissue viability, however one service user case tracked was found to have nutritional needs identified in the daily records and weight records, yet the nutritional risk assessment had not been reviewed and updated with this information, neither was there evidence that an intake chart had been implemented. Another service users weight record had not been completed since March and the service users relative commented that the service user appeared to have lost weight. Continence issues and tissue viability appear to be well managed. One service user self medicates, however although a care plan was in place for this, there was no risk assessment in conjunction with this despite being noted Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 12 that some discrepancies were evident and no apparent action had been taken in light of this. Staff were observed to communicate with service users, relatives and other visitors in a courteous manner and to respect the privacy and dignity of service users, however comments were made that on occasions service users were left sitting on the commode in their bedroom with door left open, which is not acceptable practice. Service users reported that staff knocked before entering their rooms. Observations on the day, supported this. One service user reported that sometimes they felt staff handled them in a rough manner, but on the whole staff treated them with kindness. It was acknowledged by service users that staff did spend time wherever possible talking to them, however both service users and staff stated that they would like more time to be spent for this purpose. One service user case tracked was near the end of life and appeared comfortable and well cared for. Care charts were evident, however the service users care plan had not been updated and there was no evidence of documentation regarding the changing needs of the service user. It was reported to the inspectors that the Liverpool Care Pathway Care Plans are used, for planning care of service users who are frial or at the end of life, however this was not evident or shown to the inspectors at the visit. [The Liverpool Care Pathway is a government-led initiative to improve the quality of life for service users at the end of their life] Policies and procedures for dealing with service users who are dying and after death were not examined. Standard 11 was fully assessed at the last inspection and found to be met. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Service users benefit from, a wide and innovative programme of activities and staff, have clearly excelled in providing a stimulative environment for service users within their interests and wishes. Service users are encouraged to make choices in their daily lifestyle and reported the food provision to be good EVIDENCE: The responsibility for the provision of activities and social needs is by the activities co-ordinator, who was on holiday on the day of the inspection. There was evidence of service users art works and crafts displayed around the home. The room used for activities has been set out into varying areas, which reflect’ a home’ with domestic type furniture and features including a fire place and Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 14 sofa and dining room. Much thought has clearly been put into this and staff have sought out appropriate items to encourage reminiscence of times past. A memorabilia room has also been created with old- fashioned pictures, radio, telephone and an old juke box, publications of the royal family etc, which is commendable. The manager reported that ‘life story books’ are being devised for service users and that a more detailed assessment of service users social needs is being obtained. The aim is to implement micro care plans for activities which will include care staff assisting service users for participation in activities, and that they have the required aids and equipment from their rooms such as a pen and reading glasses for bingo. The records devised so far are kept by the activities co-ordinator and as the activities co-ordinator was not available on the day of the inspection these were not accessible. A variety of activities is provided and clearly the staff have been innovative in the improvement of this aspect of the service. Relatives spoken with reported that they were always made welcome, that drinks are offered to them and staff were praised for taking extra care and providing extra input to the service user and to keep the relatives informed when circumstances prevented them from visiting as often for a period of time. Service users and relatives meetings are held, minutes are taken and there was evidence of consultation regarding the refurbishment of the home and particularly regarding a planned move of a dining room. Those rooms examined of service users case tracked were clearly personalised. Service users confirmed that their choices and wishes were listened to and care plans supported this. One service user and a relative both scored the home 7/10 overall for standard of service provided. Service users commented that the food had improved and there was more variety. Staff members supported these comments. Service users confirmed they were offered a choice of meals on a daily basis. The lunchtime meal on the day of the inspection was observed to be appetising and nutritious. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Service users are aware of how to make a complaint. Service users are generally protected from abuse, however the manager should update herself re the reporting procedures in this area EVIDENCE: The complaint records were examined. A total of sixteen complaints were recorded since the previous inspection.[The provider wishes for the report to acknowledge that one complaint has been made since May 2005]The outcomes of complaints investigated were detailed separately. Service users and relatives reported that they felt able to complain and the evidence of so many complaints supported this. A further complaint had been, received by the Commission for Social Care Inspection, which was currently being investigated. Standard 18 was fully assessed at the previous inspection and found, to be met. There was a complaint noted which should have resulted in a referral to the adult protection unit and social services, which highlights that the manager is not fully conversant with the adult protection reporting procedures. In fairness to the manager it has also to be noted that although advice was sought from CSCI regarding the complaint, that information was omitted regarding the need to refer this particular complaint under the POVA procedures. A notification and outcome form should be submitted to the adult Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 16 protection unit. Not all staff have undertaken training in adult protection, however this is planned under the new company management. [The provider wishes for the report to acknowledge that advice from CSCI was followed by the manager and that the incident had been reported to Social Services and was documented within the service users notes] Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24, 25, 26 Service users live in a safe and comfortable environment. Their bedrooms are personalised and equipped to a satisfactory standard. Laundry facilities were adequate and the home clean and free from mal odour. EVIDENCE: The communal areas appeared homely, comfortable and adequately furnished. Adequate space is provided throughout. The home is purpose built, and grab rails and facilities for disabled service users are provided throughout. Call alarms were sited around the home. A programme of refurbishment is Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 18 underway which includes the provision of shower facilities and a re-siting of a dining room and smoking area. Toilets and bathrooms meet standards. The exterior of the building was now safe, after boundary fencing has been erected for the old hall, which is adjacent to the home and a drainage system in the car park has now been repaired. The car park, has been divided up, with marker and give way lines. The rooms of service users case tracked were found, to be adequately furnished and carpeted. Rooms are personalised with service users own possessions and meet with safety standards and have en-suite facilities. The temperature of the water in one sampled en-suite facility was noted to be slightly above the safe temperature level and the handyman has been advised regarding this. One room was found to have a trailing cable to a call alarm, which has an extended length to meet the requirements of the service user. But is a trip hazard for visitors and staff. Action should be taken to further extend the cable so that it can be sited around the room. It is recommended that the assessment documentation includes, the opportunity for service users to be provided with a key to their room unless a risk assessment states otherwise. The laundry appeared well organised, although a new dryer was reported to be expected by staff, and not yet in place. Practices for infection control were noted to be satisfactory and staff, have been issued with antibacterial hand wash that affix to their belts. The home was clean and fresh smelling overall. One room did have a mal odour, but the manager reported that a new carpet was to be fitted shortly. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The staffing numbers meet the required minimum staffing levels however, a staffing review is needed to ensure that all needs of service users are met at all times. The level of training provided in the home is satisfactory. Service users and staff would benefit from staff being provided with training for dealing with challenging behaviour and abuse awareness. EVIDENCE: Staffing rostas were examined and found to be satisfactory, however there was a large number of service users who had been found after falls during the night time/early morning periods. The night staff shift commences at 7.30pm and this means a reduction in staffing to night levels, which is not satisfactory. Day time staffing hours should be provided to at least 9.30/10pm. It is therefore recommended that a staffing review take place to address these issues. It was also discovered that night staff are expected to undertake some laundry duties, which obviously reduces staffing numbers on the floor, when staff are attending to laundry. The inspector initiated a call alarm and observed that it took four and a half minutes to be answered. Later a service user was noted to Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 20 be waiting four minutes before staff reached them. The manager is requested to address this and endeavour to reduce waiting times for call alarms. It became apparent that a volunteer had been recruited to cover the absence of the activities co-ordinator, however the legal requirements for the recruitment of volunteers had not been followed regarding POVA first [Protection of Vulnerable Adults list] and criminal records disclosure check so an immediate requirement was set to prohibit the person from working unsupervised with service users until the necessary checks had been undertaken and found to be satisfactory. Staff personal files were not examined as part of this inspection and will be covered at the next inspection. Staff reported training had been undertaken in fire training, health and safety, manual handling, A programme for first aid training is underway to encompass all staff in the next few months. The new provider has in house trainers and a full range of training has been arranged over the next twelve months. Where staff, miss the training at Berry Hill through sickness or holidays, they can attend one of the other local homes owned by the same provider. Training should be provided for staff in dealing with challenging behaviours. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, 36 Service users are safeguarded by the accounting and financial procedures of the home. Staff, are appropriately supervised. Service users are consulted and systems are in place for quality monitoring. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 22 EVIDENCE: The home was taken over only twelve weeks ago and the manager is slowly obtaining appropriate paperwork and procedures relevant to the new provider. A business plan for the refurbishment of the home was available. The manager reported that monthly quality audits are undertaken. Service users surveys are not yet in place however there was evidence of service user consultation in the home. Where the home keeps monies on service users behalf, a sample of records were examined, these appeared to be satisfactory apart from a lapse in two signatures of recent transactions. Formal staff supervision is taking place, however this could be developed further as specified in the standard to cover all aspects of practice, philosophy of care in the home and career development needs. It is also good practice to address the areas listed as the General Social Care Councils Code of Conduct with staff during the supervision process. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 23 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 2 2 3 2 4 3 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 3 3 3 3 3 3 3 Score Standard No 7 8 9 10 11 Score 2 2 x 2 2 Standard No 27 28 29 30 2 x 2 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 3 34 3 35 3 36 3 37 x 38 x Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 24 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. 2. Standard OP7 OP7 OP8 Regulation 15 12, 13, 14,15 Requirement Ensure service users needs are met on a daily basis and documented as such Ensure specific care plans are implemented for challenging behaviour and nutritional needs as identified during the inspection. Ensure care plans and reviews are up to date and evaluated appropriatly and as service users needs change. Ensure risk assessments and ongoing monitoring is in place where service users are self medicating Undertake a staffing review to ensure service users needs are met by sufficient levels of staff at all times. All volunteers must undergo the same recruitment procedures as staff employed in the home. An immediate requirement is set that the volunteer planned to undertake activities with service users is not permitted to do this without satisfactory recruitment checks, i.e, Pova First and CRB checks. Timescale for action 18th October 2005 18th October 2005 18th October 2005 18th October 2005 18th October 2005 18/7/05 2.15pm 3. OP7 OP11 12, 13, 14,15 12, 13, medicines Act 18 4. OP8 5. OP27 6. OP27 7,9,19 Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 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. 2. 3. 4. 5. Refer to Standard OP1 OP2 OP3 OP7 OP8 Good Practice Recommendations All service users should be issued with an individual copy of the service user guide Service user contracts should be held within their personal care files. The assessement documentation and care plans should include footcare Care plans and risk assessements should be reviewed monthly A seperate record for healthcare checks should be used within the care file and the evaluation of these should be included in the wkeyworker weekly diaries to ensure these appointments are not overlooked. Improve staff practices regarding ensuring the privacy and dignity of service users is respected as identified. The acting manager should update her knowledge on the reporting procedures under adult protection. Include the issue of bedroom door keys and lockable facilities in the assessement and care plan process Provide training for staff in challenging behaviour and abuse awareness as planned. Implement service user surveys. 6. 7. 8. 9. 10. OP10 OP18 OP24 OP30 OP33 Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road, Nottingham NG2 1RT 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. Extracts may not be used or reproduced without the express permission of CSCI. Berry Hill Care Home C02 C53 S40343 Berry Hill V235562 180705 Stage 4.doc Version 1.40 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. 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