Inspection on 27/11/08 for Berry Pomeroy

This inspection was carried out on 27th November 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berry Pomeroy 06/02/07

Berry Pomeroy 01/12/05

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

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St Joseph`s

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Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Berry Pomeroy 26-28 Compton Street Eastbourne East Sussex BN21 4EN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Nigel Thompson     Date: 2 7 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Berry Pomeroy 26-28 Compton Street Eastbourne East Sussex BN21 4EN 01323720721 01323639032 info@berrypomeroy.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Eastbourne Free Church Women`s Council care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Residents should be older people aged sixty-five (65) years or over on admission. The maximum number of residents to be accommodated is twenty six (26). Date of last inspection Brief description of the care home 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 residents have a single room, many of which are now en-suite. There is a well-tended garden to the rear of the property. Fees as of 27 November range from £445.00 - £600.00 per week. 0 Over 65 26 Care Homes for Older People Page 4 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection took place over five hours in November 2008. It found that all of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Residents spoken to during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were twenty two residents living at the home. The inspection involved a tour of the premises, examination of documentation including care plans and staff files, discussion with seven residents, three members of staff and consultation with the Registered Manager and Finance Manager. The focus of the inspection was on the quality of life for people who live at the home. Care Homes for Older People Page 5 of 26 Responses from a CSCI service users survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 7 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 8 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The thorough admission policy and procedure ensures that residents are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Documentation, including a comprehensive Statement of Purpose and Brochure ensures that prospective residents and their relatives have sufficient information about the home and the services provided. Evidence: Comprehensive information relating to Berry Pomeroy is made available to prospective residents and their relatives. A detailed Statement of Purpose and concise Brochure are in place, including Aims and Objectives, Services and Facilities and details of the management and staff. Both documents have evidently been reviewed and updated this year to accurately reflect the current situation within the home. From discussion, it is evident that the manager is fully aware of the importance of a Care Homes for Older People Page 9 of 26 Evidence: thorough needs assessment, as part of the admission procedure. Documentary evidence was in place of a full and comprehensive needs assessment having been carried out, in respect of residents recently admitted to the home. The detailed pre admission assessmnent includes all personal care and support needs, any mental health and mobility issues, social and cultural needs and family involvement. It was noted that the assessment is routinely signed by the prospective resident, or a relative or representative on their behalf, to confirm the accuracy of the information. The manger confirmed that prospective residents and their relatives are encouraged to visit the home and have the opportunity to look around and meet members of staff and existing residents. Residents and relatives, spoken with during the inspection, were able to confirm that the home meets their individual needs and aspirations: Everyone here is so kind. They cant do enough for you. Ive no complaints. I cant fault the place. Everyone is so kind and helpful. The home does not offer intermediate care. Care Homes for Older People Page 10 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 care needs are met and individual care plans enable staff to meet their assessed needs in a structured and consistent manner. The systems for resident consultation and participation are good and residents are treated with respect and, where appropriate, are encouraged to make decisions about their day to day living. Evidence: Residents care plans that were viewed were found to be generally well maintained and up to date. They showed clear links with the individuals assessed needs and contained details of action and intervention to be taken by staff to ensure consistency of care. There was also evidence of plans being regularly reviewed and updated. The manager confirmed that residents and their relatives are given the opportunity to take part in developing and reviewing individual care plans. All residents are registered with local GPs and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans Care Homes for Older People Page 11 of 26 Evidence: that were examined, that all appointments with, or visits by, health care professionals are recorded. Nutritional screening is carried out as part of the initial assessment procedure. As part of their induction programme, the manager confirmed that all staff receive instruction on the principles of dignity and respect. This was evident, through discussions during the inspection, comments form relatives and from direct observation of staff interacting sensitively and professionally with residents. Up to date policies and procedures are in place for the control, storage, safe administering and recording of medication. All staff involved in administering medicines evidently receive appropriate training. This was supported by documentary evidence and through discussions with care staff. The manager confirmed that, following risk assessments, there are currently two residents in the home who maintain responsibility for self administering their own medication. However, in both cases it was noted that medicines were being kept insecurely in a drawer or bedside cabinet. Following discussion with the manager, it is required that a lockable facility be provided in each room, as necessary for the safe storage of medication. Care Homes for Older People Page 12 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 are enabled and supported to maintain contact with family and friends as they wish. Appropriate recreational and leisure activities are provided and residents benefit from menus that are balanced and nutritious, reflecting their individual likes and preferences. Evidence: From discussions with residents and their relatives and through direct observation, it is evident that some much needed stimulation within the home is provided through entertainment sessions and individual and small group activities, including music, arts and crafts, gentle exercise and various games and quizzes. Regular opportunity for worship is provided as well as Bible study and hymn singing. All residents birthdays are celebrated in the home. A monthly Calendar of events is produced and displayed and residents recreational and leisure interests are recorded in their individual care plan. The manager confirmed that where appropriate, residents are also supported to access the wider community, either individually or in small groups. Comments received from residents and their relatives indicate a general but realistic level of satisfaction with the activities arranged Care Homes for Older People Page 13 of 26 Evidence: in the home: What is provided is okay. I enjoy the quiz. You can never please everyone but I do think there is some room for improvement regarding the activities here. The manager confirmed that, in accordance with the wishes of the residents, visitors to the home are welcome, at any reasonable time. Residents may see friends or relatives in one of the lounges or in the privacy of their own room. Residents are provided with a varied, wholesome and nutritious diet. At lunchtime a choice of main meal is available and special diets are catered for. As part of a rolling menu, a daily menu is displayed, reflecting residents preferences and including seasonal variations. As part of the inspection process, I joined residents for lunch and enjoyed a satisfactory meal in good company. Positive comments received from residents demonstrated overall satisfaction with the choice and standard of the meals provided: The food is generally very good, particularly at lunchtime. Care Homes for Older People Page 14 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The open and inclusive atmosphere within the home enables residents, staff and visitors to express any concerns, confident that they will be listened to and acted upon. Residents are safeguarded from abuse through relevant staff training and robust policies and procedures. Evidence: An up to date copy of the complaints procedure is in place in the entrance hall, for the benefit of residents and visitors to the home. Residents, relatives and members of staff spoken to described how the manager operates an open door policy and is generally considered to be approachable and understanding. They confirmed that they would have no hesitation in speaking to her or making a complaint if necessary and each person was confident that they would be listened to: Everything at the home is to my satisfaction. I feel confident that if I had cause to complain it would be appropriately dealt with. The home ensures as far as is practicable that residents are protected from all forms of abuse. Updated policies and procedures are in place relating to the multi agency Care Homes for Older People Page 15 of 26 Evidence: guidelines on safeguarding adults, including a policy on Whistle Blowing. The manager confirmed that staff are also made aware of these key policies and procedures as part of their induction, foundation and National Vocational Qualification (NVQ) training and they are reinforced during staff meetings. This was supported by minutes from previous meetings and confirmed by staff, spoken with during the inspection. Care Homes for Older People Page 16 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from accommodation that is safe, comfortable, generally well maintained and decorated to a reasonable standard. However the current situation regarding bathroom facilities in the home is totally unsatisfactory. Evidence: There has evidently been little change in the physical environment at Berry Pomeroy since the previous inspection and with the well maintained decor and good quality furniture and furnishings it continues to provide a comfortable, safe and homely environment for residents. The home continues to provide a choice of communal sitting, recreational and dining areas, which are adequately furnished and well suited to their social purpose. The manager confirmed that independence and individuality continue to be promoted within the home, as far as is practicable, and this remains evident from the personalising of residents rooms, which clearly reflects individual tastes, preferences and interests. During my guided tour of the premises it was evident that there are currrently insufficient bathrooms in use, resulting in many residents having to travel to and from Care Homes for Older People Page 17 of 26 Evidence: the ground floor bathroom by passenger lift. This unsatisfactory arrangement is clearly inconvenient for residents and represents poor pactice. Following discussion with the manager it is required that this unacceptable situation be addressed. Of concern is the outdated, inaccessible and largely unused bathroom and inappropriate toilet cubicles on the first floor. It is understood, from discussion with the manager that this area is hopefully due to be redesigned in the near future, with level access, and refurbished as a spacious assisted bathroom or possibly a walk in shower room. A programme of routine maintenance, refurbishment and renewal is in place. Infection control procedures are in place and levels of cleanliness remain generally high throughout. Care Homes for Older People Page 18 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 benefit from there being sufficient skilled and competent staff on duty at all times to meet their identified care and support needs. Robust recruitment procedures and appropriate staff training help to ensure the safety and protection of residents. Evidence: Care staff employed at Berry Pomeroy have the relevant skills and are deployed in sufficient numbers to meet the assessed care and support needs of the residents. The manager confirmed that staffing levels within the home are sufficient to meet the current care needs of residents and there is always some flexibility for additional staff hours should the need arise. This was further evidenced by the current rota, viewed during the inspection, which details which staff are on duty at any given time and includes their designation. Residents, relatives and members of staff, spoken with during the inspection, confirmed that staffing levels within the home are adequate: Theres always someone around and they are all so kind and helpful. Care Homes for Older People Page 19 of 26 Evidence: Staff are sometimes very busy and not always immediately available but they normally dont take long to come and see how you are. It does get busy at times but we manage. If we are struggling or need more help, we only have to ask the manager. The manager continues to operate a thorough and robust recruitment procedure and all prospective staff are seen and interviewed by her before commencing work in the home. Personal files relating to recently appointed members of staff, examined during the inspection, were found to be generally well maintained, containing necessary information, including employment history, two references and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. However, following discussion with the manager, it is recommended that reference form be amended to include details of the relationship between the applicant and the person providing the reference. The manager stated that appropriate induction, foundation and core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. This was confirmed through discussions with staff and supported by training records examined. There is currently an impressive 80 of care staff at the home who hold the National Vocational Qualification (NVQ) level 2 or 3 in Care, or equivalent. Care Homes for Older People Page 20 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this 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 benefit from effective and efficient management and care staff who are appropriately supervised. Satisfactory quality assurance systems and adequate health and safety procedures, within the home, help to ensure the welfare of residents and staff. Evidence: The atmosphere in the home remains relaxed, friendly and welcoming. Staff, spoken to during the inspection felt valued and supported by the manager and confirmed her open and approachable style of leadership and clear and positive sense of direction. The Registered Manager is competent and experienced, having worked in the care field since 1996. She has been employed at Berry Pomeroy since 2001 and has been in her current position since September 2005. She has achieved the Registered Managers Award (RMA). Care Homes for Older People Page 21 of 26 Evidence: Through discussions with members of staff, it is evident that the manager continues to operate an open door policy, with staff encouraged and able to discuss any issues or concerns that they may have at anytime. In accordance with company policy, the manager confirmed that formal supervision is provided for all care staff on a regular basis. The homes quality monitoring system includes satisfaction questionnaires for residents and their relatives. The manager confirmed that, since the last inspection, surveys have been sent out although as yet no responses have been received. The health, safety and welfare of residents and staff remains of paramount importance within the home and staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to residents and all accidents, incidents and injuries are recorded and reported, as required. Care Homes for Older People Page 22 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 23 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 It is required that a lockable facility be provided in residents rooms, as necessary, for the safe storage of medication. Medicines are being kept insecurely in a drawer or bedside cabinet of residents who self administer. 31/12/2008 2 21 23 It is required that there be sufficient bathrooms for the number of residents and that they be appropriately situated. Currrently insufficient number of bathrooms resulting in residents having to travel to and from the bathroom by passenger lift. 31/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 24 of 26 1 29 It is recommended that the recruitment reference form be amended to include details of the relationship between the applicant and the person providing the reference. Care Homes for Older People Page 25 of 26 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!