Inspection on 01/12/05 for Berry Pomeroy

This inspection was carried out on 1st December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Berry Pomeroy 27/11/08

Berry Pomeroy 06/02/07

Berry Pomeroy 21/07/05

Berry Pomeroy 06/12/04

Berry Pomeroy 27/07/04

Berry Pomeroy 17/02/04

Berry Pomeroy 25/11/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Berry Pomeroy 26-28 Compton Street Eastbourne East Sussex BN21 4EN Lead Inspector Jon Wheeler Unannounced Inspection 1st December 2005 9.30 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 Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Berry Pomeroy Address 26-28 Compton Street Eastbourne East Sussex BN21 4EN 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) 01323 720721 info@berrypomeroy.fsubusiness.co.uk Eastbourne Free Church Women`s Council Mrs Linda Mulqueen Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated is twenty six (26). 21st July 2005 Date of last inspection Brief Description of the Service: Berry Pomeroy is a residential service registered to provide care and accommodation for up to 26 older people. The home is owned by The Eastbourne Free Church Womens Council; a voluntary organisation. The manager is supported by a committee of trustees, who visit the home and produce a monthly report. The home is in Eastbourne, close to the seafront and the town centre. It is close to shops, churches, transport links and other local amenities. The building is a large detached property, which has access to all floors via a passenger lift. All service users have a single room, many of which are now en-suite. There is a well-tended garden to the rear of the property. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 1 December 2005, starting at 9.30am and lasting for five hours. Those key standards not assessed at this inspection were assessed at the announced inspection of 21 July 2005. The inspection involved talking to the Financial Director, the senior carer on duty, two care staff and one cleaner. In addition, eight service users were spoken with on the day of the inspection. Berry Pomeroy was chosen as part of a pilot study by the Commission, where a service user handed out comment cards to people living in the home and collected them back in. Twenty-three comment cards were collected as part of the inspection process. Thanks are due to the link service user and to the home for their help and assistance in this process, which provided important, useful information about service users’ experiences of living in the home. The inspection process also included a tour of the premises; reading acre plans, records and policies and observing staff working with service users. What the service does well: What has improved since the last inspection? The service has fitted automatic closing devices to service users’ bedrooms doors, providing appropriate fire safety procedures, where it is desirable for doors to be kept open. There is an on-going maintenance plan, which ensures the home provides an attractive and homely environment. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 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. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6. The home is clear about its registration categories and does not provide intermediate care. EVIDENCE: The home does not provide intermediate care, and is senior staff spoken with were clear about the range of services and the needs the home can meet. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Care plans provided detailed information to enable the staff to meet the needs of the service users. Service users are treated with dignity and respect. Service users receive good health support from a range of services appropriate to their needs. Gaps in recording medication did not ensure the health and safety of service users. EVIDENCE: There was documentary evidence that the care plans contained comprehensive information and clear care support guidelines. There was evidence that care plans are reviewed monthly, in addition to six-monthly reviews, which include the individual service user and their family. There was documentary evidence that service users access a wide range of health services to meet their individual needs. Services regularly accessed include General practitioners. District Nursing and Chiropody. Other specialist support to accessed as required. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 10 Medication is securely stored. Where some service users administer their own medication, there was documentary evidence of assessments of their ability to safely do so, which were signed by the service user, a staff member and the Head of Home. There were numerous gaps in the recording of dispensed medication, which was discussed at the inspection, where an immediate requirement was left, for the service to ensure it accurately recorded all medication administration. Staff were observed providing sensitive and dignified care. Feedback from service users stated that staff work hard and provide sensitive and good quality care. Care plans indicated the individual service user’s preferred term of address. There was evidence that personal care is provided in private and with sensitivity and respect. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. A range of opportunities in the home and community provide stimulating activities for the service users. Service users benefit from the service enabling them to maintain contact with family and friends, with visitors being welcomed in to the home. Service users are encouraged and enabled to make choices about their care and all other aspects of their lives. Varied and nutritious meals are provided to meet the needs and preferences of the service users. EVIDENCE: There was evidence that the home continues to provide a range of activities for the service users. All service users spoken with said they were able to choose whether or not to attend activities. Some comment cards reported that the activities were not always very varied, although this was not a major issue for service users spoken to during the inspection. The range of activities in the home include quizzes, films, gentle exercise groups, church services and music. A number of the service users Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 12 access activities and facilities in the local community. There was evidence that the home is proactive in offering new activities, which service users are able to choose to access, if they so wish. Service users and two visitors confirmed that visitors are made welcome in the home. They are able to meet with service users in the communal areas, or to have privacy and meet in the service user’s own room. Service users said that they are regularly consulted about life in the home. There are regular residents meetings, where they talk about activities, food and staffing. Service users are able to bring in their personal possessions in to the home, with an inventory recorded in their care plan. There was evidence of a varied diet, offering choices for all meals. The feedback was that there was plentiful and nutritious food, which met peoples’ needs and preferences. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Service users are able to raise complaints and concerns and are protected by robust policies and procedures for complaints and adult protection. EVIDENCE: The home has a complaints policy and a book to record any complaints or concerns raised. The complaints policy is prominently displayed on the notice board near one ground floor lounge. There was documentary evidence that the staff had received adult protection training. The staff spoken with were able to demonstrate a clear knowledge and understanding of the adult protection policy and how they should act in the event of an alert being raised. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26. Service users live in a clean and tidy environment, which provides sufficient communal space and toilet and bathroom facilities. Service users have homely, personalised bedrooms, which provide them with a comfortable environment. EVIDENCE: The home provides a comfortable and relaxed environment, which is clean, tidy and well maintained. There was evidence of sufficient cleaning staff, who keep the home clean and hygienic. There was evidence of an on-going maintenance plan, which ensures the home is safe and in good decorative order. Since the last inspection, the home has fitted automatic door release systems to bedroom doors, to enable service users to keep their doors open if they are in their rooms, if they so choose. There is a range of comfortable communal areas providing sufficient space, including two large lounges, a small conservatory and a dining room. Communal areas are available for activities or for service users to meet their Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 15 friends and relatives. There is a safe, well-maintained garden at the back of the home. Service users are able to personalise their bedrooms to suit their individual tastes and preferences. All service users spoken with said that their bedrooms were kept clean and tidy and were in good decorative order. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. There are skilled and knowledge staff on duty in sufficient numbers to meet the needs of the service users. EVIDENCE: There was evidence that generally there are sufficient staff on duty to meet the needs of the service users. It was reported that there are usually four care staff on duty during the morning, three in the afternoon and two waking night staff. Staff said that there is some use of agency staff to cover sickness or annual holidays. The home is currently recruiting to a care manager role. Staff spoken with were able to describe in detail their roles and responsibilities. They were also clear about the needs of each individual service user and how those needs are met. Service users in feedback said they felt there were generally sufficient staff on duty, although some raised concerns about the levels of care required by some of the service users and therefore the staff’s ability to meet the changing needs. There was evidence that the home monitors the needs of the people living there, and had taken steps to address issues where they felt they could no longer effectively meet those needs. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36, 37, 38. The manager is open and approachable and ensures the service is run in the best interests of the service users, to meet their needs. Regular supervision and support of staff ensures service users’ needs are consistently met. Generally there are a range of checks to ensure the health and safety of the service users and staff. EVIDENCE: The manager had been in post for a few months, following the departure of the previous registered Manager. As yet, the Commission has not received an application to register a manager at the home. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 18 Staff and service users reported that the manager is approachable and supportive. There was a range of evidence that the manager is effective and efficient, and has ensured the service continues to provide good quality care to the service users. Service users felt that the home was run in their best interests, to meet their needs and provide them with a comfortable and homely environment. There was documentary evidence of regular service user meetings in addition to regular monitoring visits by the organisation’s trustees. The home has also placed a suggestions box in the main area of the home, where service users are encouraged to raise any issues, concerns or suggestions they may have about the home. There was documentary evidence that the organisation is beginning to develop a business plan. However, it is required that the plan is comprehensive, complete and available for inspection. There was documentary evidence that the home’s budget is effectively managed. Staff reported that there were good informal support mechanisms in the home. A formal supervision programme has been developed. There are monthly team meetings for all staff, in addition to the senior staff also meeting monthly. It was reported that the appraisals for staff had been postponed, but is due to start again. A range of records and policies and procedures were found to be in place and up to date. However, the home had not had a recent gas safety check to ensure the safety of the systems and appliances. There was evidence of a range of health and safety checks including fire safety equipment and electrical equipment. The home had worked hard to fit appropriate automatic door closing devices on service users bedrooms to ensure they are not inappropriately wedged open. Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 2 X 3 3 2 Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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. 3. Standard OP9 OP31 OP34 Regulation 13 (2) 18 (1) (a) 25 (1) (2) (C) 12 (1) Requirement All medications are dispensed and signed for accurately. The Responsible Individual submits an application to register a manager. The organisation produces a comprehensive business plan. (This is a requirement outstanding from 6/12/04). The home has a record of an up to date Gas safety check. Timescale for action 01/12/05 01/02/06 01/02/06 4. OP38 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Berry Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Pomeroy DS0000021050.V269261.R01.S.doc Version 5.0 Page 22 - 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. 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