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Inspection on 20/06/07 for Berry Hill Care Home

Also see our care home review for Berry Hill Care Home for more information

This inspection was carried out on 20th June 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective new residents are assessed before coming to the home to make sure that the home is able to meet their needs. Where risk assessments identify risks faced by residents these are included in care plans to minimise the risk to residents. Residents` health is monitored through observation and regular health checks. Care is provided in a way that promotes the privacy and dignity of residents. There is a designated activities lounge and there is an activities coordinator employed who provides a variety of activities throughout the week to residents so they have opportunities to do things they find meaningful and enjoyable. Visitors to the home are welcome and can take residents out and residents and relatives have opportunities to go on trips organised by the home. This ensures that residents are able to maintain relationships with families and friends. Residents are able to choose how they spend their time and are supported by staff to make choices where they are able so that residents remain in control of their lives as much as they are able.There is a varied menu providing a choice at each meal, including a cooked breakfast and food is well presented. This means that residents have a nutritious and balanced diet. The home has a complaints procedure, which is easy for residents to use and has been used to sort out small issues that arise in communal living. The home has policies and procedures for staff to follow if they suspect anyone is not being properly treated which makes sure that residents are protected from any form of abuse. The home has increased the number of bedrooms by three and everywhere was clean and tidy, suitably decorated and furnished and kept in a good state of repair, as a result residents live in a safe and well maintained environment. There is always at least 6 care staff and a nurse on duty and regular training is provided. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check. Most staff have either completed or are working towards National Vocational Qualification level 2 and regular training is provided, which means that residents are cared for by staff who have a qualification in their work and are suitably trained. There is a suitably experienced manager in post who is working towards a recognised qualification. Residents are able to express their views on how the home is run through meetings and completing questionnaires. This ensures that the home is properly run in the best interest of residents.

What has improved since the last inspection?

There were not any requirements set at the last inspection. There have been some improvements made to the building, including creating a new laundry and moving the offices to make them more accessible to residents.

What the care home could do better:

Care plans must clearly describe how resident needs are to be met so that staff know how this should be done. A clear and easy to refer to record should be made of all healthcare received by resident so that staff can make sure that resident receive the healthcare they need.An entry must be made in the Medicine Administration Record every time a resident is given medication to make sure that all medication is taken correctly. The arrangements for serving food are slow and make it more difficult for residents to express individual preferences about size of portions.

CARE HOMES FOR OLDER PEOPLE Berry Hill Care Home Berry Hill Lane Mansfield Nottinghamshire NG18 4JR Lead Inspector Stephen Benson Unannounced Inspection 20th June 2007 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 Berry Hill Care Home DS0000040343.V340689.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 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. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berry Hill Care Home Address Berry Hill Lane Mansfield Nottinghamshire NG18 4JR 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) 01623 421211 01623 428864 www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Dorothy Ann Turton Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63), Terminally ill (1) of places Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users shall be within categories OP with 1 bed registered for TI One Service user may be aged 64 years as named in application dated 24/5/05 PD 26th June 2006 Date of last inspection Brief Description of the Service: Berry Hill Park Care Centre is a sixty-three bedded care home providing nursing and residential care, owned by Southern Cross Healthcare. It is a twostorey building within the upper floor accessible by stairs and two passenger lifts. Berry Hill also has 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 users and senior carers and care assistants for personal care only service users. The 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. The manager said on 20/06/07 that the fees for the service range from £290 £519.75 per week depending on dependency needs, whether requiring nursing or residential care and method of funding. There are additional charges for hairdressing and chiropody. Further information about the home is available in the brochure, statement of purpose and service user guide or from the website: www.southerncrosshealthcare.co.uk The manager welcomes any telephone enquiries and thee is a notice in the entrance saying a copy of the latest inspection report is available in the office. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The site visit lasted for 7 ½ hours and the main method of inspection used was called case tracking which involved selecting 4 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the operations manager, the manager, staff on duty and care practices were observed. The hairdresser was spoken with during the visit. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. The registration certificate was checked and found to be incorrect and a new one has been requested. What the service does well: Prospective new residents are assessed before coming to the home to make sure that the home is able to meet their needs. Where risk assessments identify risks faced by residents these are included in care plans to minimise the risk to residents. Residents’ health is monitored through observation and regular health checks. Care is provided in a way that promotes the privacy and dignity of residents. There is a designated activities lounge and there is an activities coordinator employed who provides a variety of activities throughout the week to residents so they have opportunities to do things they find meaningful and enjoyable. Visitors to the home are welcome and can take residents out and residents and relatives have opportunities to go on trips organised by the home. This ensures that residents are able to maintain relationships with families and friends. Residents are able to choose how they spend their time and are supported by staff to make choices where they are able so that residents remain in control of their lives as much as they are able. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 6 There is a varied menu providing a choice at each meal, including a cooked breakfast and food is well presented. This means that residents have a nutritious and balanced diet. The home has a complaints procedure, which is easy for residents to use and has been used to sort out small issues that arise in communal living. The home has policies and procedures for staff to follow if they suspect anyone is not being properly treated which makes sure that residents are protected from any form of abuse. The home has increased the number of bedrooms by three and everywhere was clean and tidy, suitably decorated and furnished and kept in a good state of repair, as a result residents live in a safe and well maintained environment. There is always at least 6 care staff and a nurse on duty and regular training is provided. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check. Most staff have either completed or are working towards National Vocational Qualification level 2 and regular training is provided, which means that residents are cared for by staff who have a qualification in their work and are suitably trained. There is a suitably experienced manager in post who is working towards a recognised qualification. Residents are able to express their views on how the home is run through meetings and completing questionnaires. This ensures that the home is properly run in the best interest of residents. What has improved since the last inspection? What they could do better: Care plans must clearly describe how resident needs are to be met so that staff know how this should be done. A clear and easy to refer to record should be made of all healthcare received by resident so that staff can make sure that resident receive the healthcare they need. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 7 An entry must be made in the Medicine Administration Record every time a resident is given medication to make sure that all medication is taken correctly. The arrangements for serving food are slow and make it more difficult for residents to express individual preferences about size of portions. 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. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 8 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 Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service EVIDENCE: The home has their own assessment form to complete to help assess the needs of any prospective resident, and one was seen completed for a newly admitted resident. Staff said that the deputy manager goes to assess any residential residents and the manager or senior nurse will assess any nursing residents. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 10 Staff said they are told about new residents and assessments are available for them to read. Staff described details contained in the assessment for the newly admitted resident. The manager said that anyone is welcome to apply for a place providing they fall within the registration category for the home. The manager said that there are male and female residents all whom are of white British origin with the exception of one who is Sri Lankan. There has not been a resident from another culture at the home. There is no arrangement made for the home to provide an intermediate care service. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social needs are set out in an individual plan of care and these are met by care practices in the home EVIDENCE: The manager said a named member of staff compiles care plans and staff on duty update care plans as and when required. A sample of 5 care plans were seen and these all contained assessments, risk assessments and plans of care. There was evidence of relatives being involved in some care plans, which the manager said did tend to be a bit variable. The descriptions of care needed did not clearly describe the care required and how that was to be given, for example comments such as ‘give preference to her likes and dislikes’ and ‘assist with activities of daily living’ were seen. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 12 Care plans include details of resident’s gender, religious beliefs and any disability but did not show their ethnic origin. Risk assessments were seen for various things including nutrition, falls and pressure area care. A sample of where risks were identified were checked and these had care plans prepared for managing them. Staff said that they know where to look to find things if they were not sure about something and to check they are giving care as needed. Staff said they had checked a plan the previous day to make sure that this showed a resident had been transferred from residential to nursing care. Records showed a case tracked resident and a relative had attended a review of their care but could not remember this when asked about it. The manager said that nursing staff only provide nursing care to residents assessed for nursing care and the district nurses come to provide any nursing needed by residential residents. The manager said that they work closely with McMillan nurses when caring for residents who have a terminal illness. The manager said a record is made in the care plan when a resident receives any healthcare, however this was recorded in different parts of the care plan, making it difficult to establish what healthcare residents had received. The manager said that routine health checks are provided, including dental and sight checks, however some residents wished to remain with their own dentist or optician, which they are able to do. Staff said that they know the residents and can tell if they are not all right, including those who are not able to communicate this. Staff also said that residents’ weight is monitored weekly. A hairdresser said that residents are clean and presentable when she sees them. A resident said, “They call the doctor if I am not well, I saw one recently”. The morning medication round was observed and two staff were giving medication out, a nurse to residents receiving nursing care and senior care staff to residents receiving residential care. Staff were wearing red bibs stating they were not to be disturbed when giving medication out and were seen giving medication out appropriately. This included watching residents take their medication before signing the Medicine Administration Records, however there were some gaps in these records from previous shifts. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 13 The medicine trolleys were sited in the corridor outside the dining rooms. This meant that there were times when the trolleys were not within the sight of staff giving out medication and were left unlocked. Staff said they would prefer to have the trolleys in the dining room, but this had been stopped some time ago. The manger said that the trolleys should now be in the dining room rather than the corridor. A resident said, “Staff bring me my tablets so I don’t have to worry about them”. There is a procedure to assess whether residents are able to self medicate, and some residents administer their own creams. The manager said that promoting residents’ privacy and dignity is included in staff training and induction. Staff described good practices in promoting residents’ privacy and dignity, including explaining to residents what they are going to do and showed a notice they put on doors when assisting with personal care so they are not interrupted. A resident said, “I am happy with how staff help me”. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to satisfy their social, cultural, religious and recreational interests and needs through opportunities provided within the home, the local community and being able to maintain relationships. Residents are helped to exercise choice and control over their lives and receive a wholesome and balanced diet, although improvements could be made to the serving arrangements. EVIDENCE: The home employs an activities coordinator and there was information about forthcoming activities on the notice board. The activities coordinator was seen asking residents if they wanted to join an arts and crafts session and part of this session was observed. Residents were knitting, colouring, watching television and listening to music. There was display of things made in the activities sessions on the wall outside the activities lounge. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 15 The activities coordinator said she tries to involve as many residents as possible and where residents are not able to join in group activities she spends time with them individually in their rooms. Records showed that all residents regularly take part in some form of activity. Staff were seen talking to residents respectfully and laughing together. Staff were seen sharing appropriate information about themselves and discussing the current unsettled weather. A resident said, “I enjoy taking part in the activities, it depends how I am feeling whether I join in or not”. The manager said that visitors are welcome to the home at any time, which residents confirmed. The manager said that visitors are able to take residents out and that the home organises outings such as picnics, and that relatives are also made aware of these so they can join in if they wish. There were notices advertising forthcoming outings seen on the notice board. The manager said that no residents currently want to attend a local church, but this could happen if they wanted to. A local minister visits the home fortnightly, and another will give residents communion. The manager said that local brownies come and visit the home, and residents have been involved in judging competitions for a local nursery. A resident said, “I have been out for a long walk with my niece today”. The manager said that residents are able to choose how they spend their time, and some will stay in their rooms at different parts of the day. The manager said that they will try to support residents with anything they like or want. Staff said that residents are involved in making decisions about what they are going to wear, how they spend their time and when they get up and go to bed. Care plans referred to offering choices over what residents wanted to wear. Residents were seen using various areas of the home and were being asked questions by staff over every day matters such as what drink they wanted and where they wanted to sit. There is a cooked breakfast available up till 10.30 am after which cereals and toast are still available. One resident was seen having egg and another tomatoes on toast. The main meal is at lunchtime and dishes include gammon and pineapple, spaghetti bolognaise, vegetable bake, omelettes, salads and casseroles. There is a different type of fish on Fridays and a roast dinner on Sundays. A lighter meal is had at tea time with such things as sandwiches or scrambled egg on toast. A pudding is provided at lunch and cakes at teatime. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 16 Residents are given a menu for the following day and are asked to choose which dish they want from the options available. The cook said there are times when not all menus are retuned to her. Lunch was a choice of roast pork, carrots, sprouts, stuffing, potatoes and gravy or jacket potato with a choice of fillings. There was a chocolate mouse or yogurt to follow. Lunchtime was observed and the meal was well presented and looked appetising. Residents were sat waiting for the meal for a long time and some said they had been given vegetables they didn’t want or portions that were too large. The serving took a long time as all meals were plated out in the kitchen and taken to residents by staff, but once this was completed staff were assisting those residents who require assistance with eating in an appropriate manner. The manager said she would look to see if there were ways of improving the serving of the meal so residents aren’t left waiting so long. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel able to complain if something is not to their liking and any allegations of abuse are treated seriously. EVIDENCE: The home has a complaints procedure and a book to record any complaints in. There were 9 complaints recorded since June 2006 Records of complaints made included details of the investigation and outcome. There were three complaints fully substantiated and one partly substantiated. Complaints made included the use of the car park when meetings take place, not being able to hear the doorbell and someone not having their hair done at the usual time. A resident said, “The only complaint I have is the length of time I am left sitting at the table after meals”. The manager said she would look into this complaint. The manager said that she had just downloaded the latest Adult Protection Procedures from their website. The home has a whistleblowing policy. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 18 The majority of staff have received training on safeguarding adults and the remainder are due to do so shortly. There has been one recent allegation reported to Social Services, who have investigated and said that there is no case to answer. Staff said that external doors are alarmed so they know if a resident is trying to leave the building. A resident said, “I feel quite safe here, I have never been mistreated”. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: The home is well laid out and has wide corridors and everywhere is accessible to wheelchair users. The home was well maintained and the handyman said all repairs are seen to promptly. Approval has been given to use three new bedrooms. In addition the offices have been relocated, and a new laundry has been built, which has dirty and clean areas to reduce the risk of infection. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 20 There were pictures around the home reflecting previous times with things such as old adverts and films. Staff said that they thought the building was suitable for its purpose and the cleaners responded promptly to anything that needed to be cleaned. Protective clothing was available and staff were seen using this. The majority of staff have completed training in infection control and the manager said the remaining staff will be doing so shortly. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient and suitably trained staff employed at the home, ensuring that residents needs can be met. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The home has assessed their minimum staffing levels to be 7 care staff and a nurse in the morning, 6 care staff and a nurse in the afternoon and 4 care staff and a nurse overnight. In addition the home employs an administrator, kitchen staff, handyman and housekeepers. The majority of staff are female of white British origin and of varying ages, although there are some male staff and some from differing ethnic backgrounds. Staff said there were enough staff for them to be able to carry out their duties, although a resident said, “I don’t think there is always enough staff on duty”. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 22 There are almost 50 of care staff who have passed National Vocational Qualification level 2 or higher and a further four staff are currently working towards one of these. Staff files seen showed that the correct recruitment practices are followed, although references for one member of staff could not be located, but were recorded on the checklist as having been received. The administrator confirmed by email after this visit that these had been found between other papers in the file. The home follows their equal opportunities policy in the recruitment of new staff. Staff spoke of various courses they had completed or were currently attending, and the staff training record showed which staff still had some mandatory training to complete as well as those who were due to have their training updated. The manager said that all staff are planned to complete the mandatory training. The manager said that some staff are being trained to become manual handling trainers so they can provide regular training to staff. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable management systems in place for the smooth running of the home and to protect residents. Residents express their views on how the home is run. EVIDENCE: The manager has worked at the home since January 2005, and has been the registered manager since October 2005. The manager is a trained nurse and expects to complete the Registered Managers Award in August 2007. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 24 Staff said they thought the home was well managed and that the manager is approachable. The manager undertakes monthly audits of services provided within the home. The manager said residents and relatives customer satisfaction surveys are given out on a regular basis but there is a poor response rate for these. The home will hold money for residents to pay for hairdressing, chiropody and other incidentals. A record is made of each transaction, signed and witnessed. Receipts are kept when available. The provider regularly audits the residents’ accounts. The manager said that all the required health and safety checks are carried out at the required frequency, and there are service contracts in place for servicing all the equipment. Dates of tests were recorded in the Annual Quality Assurance Assessment showing they are regularly carried out. A sample of these were looked at and found to be correct. Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 25 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 x X 3 Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(1) Requirement Care plans must clearly describe how resident needs are to be met. This will ensure that staff know how to meet residents’ needs. When medication is administered to residents it must be clearly recorded in the Medicine Administration Records. This will ensure that people receive the correct levels of medication. Timescale for action 01/08/07 2 OP9 13(2) 01/07/07 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 Refer to Standard OP8 OP15 Good Practice Recommendations A clear and easy to refer to record should be made of all healthcare received by resident so that staff can make sure that resident receive the healthcare they need. Current arrangements for serving food should be reviewed so meals are served quicker and residents are able to make choices. DS0000040343.V340689.R01.S.doc Version 5.2 Page 27 Berry Hill Care Home Berry Hill Care Home DS0000040343.V340689.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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