Inspection on 21/07/05 for Berry Pomeroy

This inspection was carried out on 21st 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 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 01/12/05

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 Announced 21 July 2005 12:00 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. 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 H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Berry Pomeroy Address 26 - 28 Compton Street Eastbourne East Sussex BN21 4EN 01323 720721 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) Eastbourne Free Church Womens Council Mrs Linda Mulqueen Care Home 26 Category(ies) of Old age, not falling within any other category. registration, with number OP (26) of places Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty-six (26). Date of last inspection 6 December 2004 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 Women’s Council; a voluntary organisation. The registered 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 ensuite. There is a well-tended garden to the rear of the property. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection, by two inspectors, started at 12.15pm on 21 July 2005 and lasted for about four hours. The process included an inspection of the environment; talking to nineteen of the service users, five of the staff and two family members of service users; discussions with the manager and deputy manager and with four trustees of the organisation; reading care plans, records, policies and the completed pre-inspection questionnaire; observing staff working with service users and inspecting the systems for administering medication. What the service does well: What has improved since the last inspection? The service provides regular and effective supervision to the staff team. There was evidence of on-going maintenance work and decorating to provide a safe, homely and relaxed environment. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 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 H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4, 5. The Statement of Purpose and Service User Guide detail the services offered by the home. Comprehensive pre-admissions assessments enable the service to meet the needs of any new service users. Prospective service users and their families are able to visit the home prior to moving in. EVIDENCE: There is a Statement of Purpose and Service User Guide that clearly outline the range of services offered by the home. There was documentary evidence of pre-admission assessments taken by the home, prior to service users moving in. The pre-admission assessments ensure that the needs of the prospective service users can be met by the home. A service user who had recently moved in to the home reported that she and her family had visited prior to her admission and had been reassured that she would be well cared for and have her needs met by the home. A family member said that she had felt reassured that the home would provide good care for her relative. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 9 One service user spoken with had said she had been given the opportunity to have short respite care breaks in the home and had therefore been aware of the services in the home and its ability to meet her needs. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9, 10. Care plans contain comprehensive information about the service users. The service ensures the health needs of the service users are met and medication is stored, dispensed and recorded accurately. Service users are treated with dignity and respect. EVIDENCE: Comprehensive care plans identify the needs of the individual service users and clearly state how those needs should be met. There was documentary evidence of risk assessments which enabled the staff to identify and manage any risks to service users in the home. There was documentary evidence that care plans had regularly been reviewed and updated. The care plans demonstrated that the service is able to ensure that service users have their health needs met. All service users are registered with a local GP and can access care from District Nurses and a range of specialist services to meet their needs. The management team and the staff were able to clearly describe the health needs of the service users and how those needs are cared for. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 11 Medication is kept securely in the home. There are a range of robust policies to ensure the safe storage, administration and recording of medication. All the staff who administer medication have completed relevant training. All medication had been recorded appropriately and accurately. All the service users spoken with said that they felt they were treated with dignity and respect by the staff. Staff were observed providing friendly and sensitive care. In the positive feedback from the service users, one said that the staff “could never do enough for me, and if I call, they come immediately to help”. Staff were seen knocking on bedroom doors before entering. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15. Service users have their interests met by a wide range of activities and opportunities in the home and in the community, including maintaining relationships with their families and friends. Service users are able to make choices about their lives in the home. Food provided is nutritious, appealing and of good quality. EVIDENCE: There was evidence of a range of activities being provided in the home, including games and quizzes, singing and Church services. Service users said they had the opportunity to take part in activities, although some said they chose not to attend. Many of the service users are also able to access activities and facilities in the community. Service users are encouraged by the staff to maintain regular contact with their family and friends. One relative said that she was always made welcome in the home by the staff. The home holds regular residents meetings to enable service users to raise any concerns or issues they may have with the running of the home. There is also an annual survey of service users views about the home. All the service users spoken with said that they felt able to raise any concerns they may have with the manager or the staff. Service users are able to make choices in all aspects Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 13 of their care, including what to eat, when to get up and what activities they would like to do. There is a four week menu which offers a varied diet, catering for the dietary requirements of each of the service users. All the service users spoken with said that the food is good and plentiful. They also confirmed they are able to choose something different from the menu if they wish. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 14 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 standard(s) 16, 17, 18. Complaints and adult protection policies protect the service users. Service users have their legal rights protected. EVIDENCE: The home has complaints and adult protection policies. Service users spoken with said they felt able to raise with the manager and staff any concerns or complaints they may have. One complaint had been made by a service user about a member of staff, but this had been investigated and resolved. The staff were in the process of doing adult protection training. All service users are registered to vote, whilst most use a postal vote. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 23, 24, 25, 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. Fire doors kept open with wedges did not adequately address the safety of service users and staff. 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. However, it is required that the home immediately removes any wedges from fire doors. To ensure the safety of service users, fire doors kept open should be fitted with an approved automatic closing device. There is a range of comfortable communal areas, including two large lounges, a small conservatory and a dining room. One communal area was being used Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 16 for activities, whilst another lounge was being used as a quiet area for service users to read and chat. There is a safe, well-maintained garden at the back of the home. Sixteen bedrooms have en-suite facilities in addition to the communal bathrooms and toilets. Each service has their own room, which were homely and personalised with their own possessions. All the service users spoken with said that they were happy with their bedroom. There is a passenger lift to each floor in the home. Staff were observed helping service users in the lifts and in the home to ensure they were safe. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30. The needs of service users are met by a dedicated, skilled staff team who are well-trained and supported. There are robust employment procedures to ensure skilled staff are employed to meet the needs of the service users. EVIDENCE: There is a skilled and experienced staff team who are aware of, and able to meet the needs of the service users. The staff rota indicated that there are sufficient staff on duty to provide good levels of care to the service users. Staff were observed providing skilled and sensitive care to the service users. All the service users spoken with said that the staff provide sensitive and good quality care. One service user said that “The staff are very kind and nothing is too much trouble”. The home has a robust employment procedure, with evidence of application forms, interviews, references and CRB checks and photographic identification for all new staff. There was documentary evidence of staff undertaking a wide range of training courses including NVQ courses, adult protection, death and bereavement, moving and handling, supervision, first aid, care skills, infection control, medicines management and fire safety. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 36, 37, 38. 31, 32, 33, 34, A skilled, knowledgeable manager who is approachable and supportive to service users and staff runs the home. The home is run in the best interests of the service users, although insufficient budget planning does no guarantee the financial stability of the home. Some procedures do not adequately address the safety of service users and staff. EVIDENCE: The manager is an experienced and skilled practitioner, who provides a clear ethos and direction for the home. The manager and deputy provide an effective management team, which ensures the smooth-running of the home to meet the needs and preferences of the service users. All the service users and staff spoken with praised the manager, describing her as dedicated, approachable and supportive. There was documentary evidence of a comprehensive induction programme for all new staff, to enable them to understand and meet the needs of the service users. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 19 The home looks to meet the needs of the service users and is run in a way which respects their rights, choices and dignity as well as enabling them to keep regular contact with the local community; their family and friends. The organisation carries out regular monitoring reviews to ensure the continuing good quality of the home. Two trustees were carrying out an unannounced monitoring visit at the time of the announced inspection. Whilst the organisation continues to support the home to providing good quality care, it has been a continuing requirement that it produces an effective and comprehensive business plan to ensure the financial stability of the home. The home has robust financial procedures to ensure the safety of service users’ money. Most service users have their money administered by their families. Where the home holds service users money, there is clear recording of any expenditure. There was documentary evidence, supported by reports from staff that there is a regular supervision timetable for all staff. Staff said that they were well supervised and supported by the management team, who they also described as approachable and effective. The policies and records relating to the effective running of the home were up to date and accurate. There was evidence that the home’s policies had been reviewed and updated in June 2005. The home has a range of health and safety procedures. However, a number of fire doors were found propped open with wedges, which in the event of a fire would not give adequate protection to service users and staff. The home should ensure all fire doors are closed, or that they are fitted with approved automatic closing devises. There are regular checks on the emergency lighting, fire alarm systems and water systems. The temperatures of the fridges and freezers are taken daily to ensure their effective operation. There was documentary evidence of recent fire drills. Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 2 3 2 Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 36 38 Regulation 18 (2) Requirement The organisation produces a comprehensive business plan All fire doors should be kept closed, or fitted with an approved automatic closing device. Timescale for action 1/12/05 21/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Berry Pomeroy H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 H59-H10 S21050 Berry Pomeroy V218115 210705 stage 4.doc Version 1.30 Page 23 - 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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