Inspection on 30/01/06 for Berrywood

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berrywood 08/12/06

Berrywood 28/08/05

Berrywood 22/03/05

Berrywood 06/09/04

Berrywood 11/03/04

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Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Berrywood 130 Berry Lane Rickmansworth Hertfordshire WD3 4BT Lead Inspector Claire Farrier Unannounced Inspection 30th January 2006 17:45 Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 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 Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Berrywood Address 130 Berry Lane Rickmansworth Hertfordshire WD3 4BT 01923 770132 01923 770132 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) Watford and District Mencap Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5), Physical disability over 65 of places years of age (5) Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate 1 person with physical disability (aged over 65 years) 28th August 2005 Date of last inspection Brief Description of the Service: Berrywood is a care home providing personal care and accommodation for five people with learning disabilities, one of whom may also have a physical disability. It is owned by Watford and District MENCAP, which is a voluntary organisation. The home was opened in 1991 and consists of a two storey semi-detached house, which is indistinguishable from the neighbouring properties. It is situated in a residential area of Rickmansworth, within walking distance of local shops and on a bus route for access to the town centre. All the homes bedrooms are single and one has a wheelchair accessible ensuite bathroom. The home has a large garden that is easily accessible for all service users. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second inspection of the year. It was carried out over one evening, and including preparation time, a total of three hours was allocated to it. The focus of the inspection was to inspect the core standards that were not covered in the last inspection. The home is registered for five residents, but there are currently three vacancies. The inspector spoke with both the residents and one member of staff, carried out a brief tour of the premises and looked at care plans and risk assessments. The acting manger was not in the home during the inspection, and the only member of staff was an agency worker. It was therefore not possible to inspect the staffing and training records and the quality assurance and complaints procedures, and an additional visit will be arranged in order to complete the inspection of these core standards. The home continues to provide a good quality of care although the residents’ care plans were not available on this occasion. The residents are happy in the home and the atmosphere is relaxed and homely. One new requirement was made to address a health and safety concern. The requirements and recommendations that have been repeated from the previous report will be addressed during the additional visit. What the service does well: What has improved since the last inspection? The first floor bathroom has been improved by a thorough clean to remove the stains on the floor, and a new seat for the bath hoist. The whole house looked clean and well maintained on this occasion. Good individual risk assessments are in place for each resident, and they have been reviewed to ensure that they meet their current needs. The whistle blowing policy was amended as recommended. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 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. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 No evidence was seen of any change in the home’s licence agreement. EVIDENCE: The licence agreement was seen in one resident’s file. There has been no change to the format since the last inspection. It is not available in a format that can be understood by residents who are unable to read, and it does not specify the room to be occupied or the fees charged. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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 and 9 There was no evidence on this occasion that appropriate care plans are in place. The care plans should provide information on all the residents’ personal care and health care needs, written with their involvement, in order to enable the staff to provide a good quality of care. Risk assessments are in place for the home and for individual residents, but they need to be reviewed and updated to ensure that residents are protected from avoidable hazards. EVIDENCE: The files for both the residents were seen, and one was inspected in detail. The care plan file contained information on the resident’s health needs and recent reviews of his needs. However there was no care plan in either file. Care plans were seen for both residents during the last inspection. On that occasion they were assessed to be well written, and to contain all the information required to assist the staff to provide appropriate care and support, including details procedures and reference to appropriate risk assessments. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 10 The risk assessment files were seen. Individual risk assessments are in place for each resident, for example for making tea, having a bath and attending a football match, with reference to behaviour guidelines where appropriate. The risk assessments provide good procedures for the assessed activities, but they do not on their own constitute a care plan. The member of staff on duty was not aware of any other files for the residents, or of any assessed care plan needs other than the risk assessments. The risk assessments seen for individual residents were up to date, but the generic risk assessments for the home were written in March 2004 and have not been reviewed since then. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The residents are encouraged and enabled to maintain a good relationship with their families. EVIDENCE: The two residents were seen to have a good relationship with each other. They enjoy each other’s company, and were relaxed and laughing in the lounge during the inspection. One resident attends the day centre from Monday to Friday. She has a befriender from Guideposts, and they go out together once a fortnight. She talked about Christmas, when she went to her sister’s house for the day. The other resident spent Christmas day at the one of a member of staff. His father and brother visit him regularly. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Some details of the residents’ healthcare needs were seen in their files, including guidelines for managing behaviour and a record of visits to the doctor and chiropodist. However due to the care plans being unavailable it was not possible to fully inspect and assess the quality of care provided. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The home provides a comfortable and well maintained environment for the residents, and the staff maintain a good standard of cleanliness and hygiene. EVIDENCE: Berrywood is a two storey semi-detached house, which is indistinguishable from its neighbouring properties. The home is situated in a residential area of Rickmansworth, within walking distance of local shops and on a bus route for access to the town centre. There is a large garden that is easily accessible for the residents. The home appeared to be clean and well maintained, and there was a relaxed homely atmosphere. The bath lift in the first floor bathroom has been fitted with a new seat. The residents’ bedrooms were not seen on this occasion. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The home is staffed by experienced support workers in sufficient numbers to meet the needs of the current residents. EVIDENCE: One agency member of staff was in the home during the inspection. As best practice the home should be in the charge of a permanent member of staff at all times. However the agency worker has worked for the home for some time and has knowledge and experience of the residents and their needs. The staffing rotas seen show that there are two care workers on duty from 7am to 3pm, and one from 3pm to 11pm who also sleeps in over night. The acting manager is also included in the rota, but on approximately two out of every three Fridays she is extra to the rota. The staff communicate with each other about the residents’ needs and events with handover sheets and messages in the staff communication book. It was reported that there are three permanent care workers employed by the home in addition to the acting manager, and three or four regular agency staff. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 and 42 The home maintains appropriate policies and procedures to ensure that the residents are provided with a good quality of care and protected from harm. EVIDENCE: Watford and District Mencap have a comprehensive set of policies and procedures. The Vulnerable Adult Protection Guidelines has been amended and now includes contact details for CSCI, Hertfordshire County Council contracts section and Adult Care Services Emergency Duty. The old policy, which addresses only sexual abuse rather than the full range of needs and concerns for protection of the residents, is also in the file and should be removed. The health and safety records were not inspected on this occasion, but one issue of concern was noticed during a tour of the premises. In an unlocked cupboard under the kitchen sink there was a container of descaler marked with Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 17 a symbol indicating that it is an irritant and could be hazardous to health. It was removed immediately. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X 2 2 X Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 19 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. Standard YA6 Regulation 12(1) & 15 Requirement The residents’ care plans were not available for inspection, and the member of staff on duty was not aware of any care plans. Timescale for action 31/03/06 2. YA34 The registered person must ensure care plans are in place to provide adequate and appropriate information on all the resident’s needs. The care plans must be available in the home. 19(1)Sc2 All required information for 17(2)Sc4(6) each member of staff must be kept in the home, including evidence of a satisfactory CRB check. This standard was not inspected on this occasion, and the requirement has therefore been repeated. 31/05/05 Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 20 3. YA39 24 A system for monitoring the quality of care must be established, that focuses on the consultation with the service users and other involved people, and provides feedback on the process and the results of the consultation. This standard was not inspected on this occasion, and the requirement has therefore been repeated. A container of descaler was seen in an unlocked kitchen cupboard. All substances that may be hazardous to health must be stored securely at all times. 31/08/05 4. YA42 13(4)(a) 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations The homes licence agreement should be produced in a format that can be understood by the residents. It should also contain all the information specified in Standard 5, and in particular the room to be occupied and the fees charged for each resident. This recommendation has been repeated from the previous inspection report. Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 21 2. YA6 The care plans contain comprehensive information on all aspects of the residents life, but there is no evidence that the residents are involved in writing and reviewing their care plans, in line with PCP. It is recommended that the staff should encourage and enable residents to provide a realistic input into their care plans and reviews, for example by setting their own targets or monitoring their own progress. This recommendation has been repeated from the previous inspection report. The homes generic risk assessments have not been reviewed since they were written. The risk assessments should be reviewed and updated to ensure that they provide current and accurate information. This recommendation has been repeated from the previous inspection report. 3. YA9 Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Berrywood DS0000019290.V281778.R01.S.doc Version 5.1 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. 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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