Inspection on 08/12/06 for Berrywood

This inspection was carried out on 8th December 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berrywood 30/01/06

Berrywood 28/08/05

Berrywood 22/03/05

Berrywood 06/09/04

Berrywood 11/03/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Berrywood 130 Berry Lane Rickmansworth Hertfordshire WD3 4BT Lead Inspector Angela Dalton Unannounced Inspection 8th December 2006 11:10 Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 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.V323135.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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.V323135.R01.S.doc Version 5.2 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 Manager post vacant 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.V323135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate 1 person with physical disability (aged over 65 years) 30th January 2006 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.V323135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection consisted of a site visit conducted by one Inspector on 8th December 2006 between 11.10am and 5pm. The Inspector spent time talking to service users and staff, examined documentation and toured the premises. The fees that the home charges were not available on the day of inspection. There are currently two vacancies at Berrywood and a registered manager has yet to be appointed. One service user is over the age of sixty- five. What the service does well: What has improved since the last inspection? What they could do better: The home environment would benefit from redecoration but this is currently impeded by the number of large cracks within the home (which are under investigation. Some of the cracks are occurring under wiring and the safety of the electrics must be checked. Other health and safety improvements are needed: radiators should be risk assessed and emergency lighting checks should be regularly conducted and recorded. Care plans need to be more explicit in how identified needs are monitored, managed and met. Recruitment records were incomplete and did not reflect how the safety of vulnerable service users is assured. Although a complaints procedure is available there is no formalised system in place to record complaints and track any action taken. Medication and financial systems require some fine tuning to ensure that they are fully effective. Service user documentation should be more user friendly – none of the documentation has been tailored to meet the needs of people with learning disabilities. An up to date Insurance certificate was not displayed on the day of inspection Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome is adequate. An assessment of service users needs is conducted prior to admission to the home but service users are not formally notified that the home can meet their needs. The statement of purpose and service users’ contracts are not written in a user friendly style. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users are assessed prior to moving into the home and this forms the foundation for the care plan. The company has recently reviewed its assessment and this is used in conjunction with any information or assessment from the multi disciplinary team. Service users have not been notified formally Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 9 that Berrywood is able to meet their needs and reflected that both the service user and the home are content for the service user to remain living at the home. There have still been no changes to the format of the service users’ contracts despite previous recommendations. It is not available in a format that can be understood by service users, who are unable to read, and it does not specify the room to be occupied or the fees charged. The statement of purpose is not in a style or language appropriate to the needs of service users and this should be addressed. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome is adequate. Care plans require development to illustrate how individual needs are met. Service users are encouraged to take assessed risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two service users have moved into the home in the past six months. Comprehensive assessments of need are in place and individual needs are identified. Care plans are still being developed but they do not reflect the successful work the home has achieved with regard to the resettlement process or how this was accomplished. Further work is required to illustrate Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 11 how individual’s health needs are met e.g. epilepsy and how staff monitor individual requirements. A wealth of information was available about assessed needs but there was no guidance available as to how needs were met. Care plans need to be developed to co-exist with risk assessments. Where service users manage their own money or medication evidence should demonstrate how capability has been assessed and reviewed. Watford and District Mencap have not yet introduced person Centred Planning (PCP) to Berrywood. PCP illustrates how service users’ wishes and desires are facilitated by the home. Service users participate in making decisions and are involved in menu planning, organizing activities and deciding the home’s colour scheme. Risk assessments are in place but, like care plans, some developments are needed to reflect how identified risks are met. This is further discussed in later chapters. Service users are encouraged to take assessed risks and this ensures levels of independence are maintained. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 13 12,13,15,16,17 Quality in this outcome is good. Service users are encouraged to make choices regarding meals, activities and maintain contact with friends and family. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users attend work, daycare or college. One service user is currently being supported to reduce their attendance at a daycentre illustrating that their attendance is down to individual choice. Activities within the home are chosen by service users and they are supported to socialise as a group, individually or with friends. A recent holiday in the Isle of Wight was enjoyed and one service user showed photographs to the Inspector illustrating that a good time had been had by all! Family contact is maintained and encouraged and this is an important factor is successfully supporting service users to move into the home. One service user returned from food shopping during the inspection and confirmed that they were involved in menu planning and choosing ingredients for meals. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome is adequate. Documentation does not sufficiently reflect how health and medication needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One service user who has lived at Berrywood for the past two months is currently drawing up a protocol regarding their preference of staff to assist with personal care. The service user has requested female staff to assist them and this is borne in mind when the rota is devised. Their request will contribute to the overall care plan. It was clear that service users living at Berrywood are able to maintain high levels of independence with support from staff. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 15 As discussed earlier, a high standard of care is delivered to service users from staff and they evidently know individuals well. This is not reflected in care plans and documentation does not illustrate how good health is maintained and why service users mange individual conditions well e.g. diabetes, epilepsy. Medication is stored appropriately in a locked cupboard in each service user’s bedroom. However, a record of storage temperatures is not kept to reflect that medication is kept at the correct temperature. Handwritten instructions were unsigned on Medication Administration Record sheets and this must be rectified. One service user self medicates which illustrates that his independence is maintained. More explicit information is needed to reflect how competence is assured and reviewed. Records must reflect how amounts of medication are checked and service user safety is assured. The home used the NOMAD system that is a dossett system supplied pre-filled by the pharmacist. The home does not currently have provision for controlled medication or that which would require refrigeration. The Inspector suggested that some consideration be given to how this provision could be implemented at short notice. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome is adequate. A formal complaints record is not in place. The financial security of service users could be better assured. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Those service users whom the Inspector spoke with confirmed that they could approach staff and discuss any concerns that they may have. A keyworker system is currently being implemented which will identify a named member of staff for each service user. As stated earlier the views of service users were evident with regard to meal choices and activities. A complaints procedure is in place but there is no formal recording system to reflect what action was taken, the outcome and time period taken. Some of the details in the policy are out of date. Staff had a good awareness of adult protection and what action to take should a concern arise. Service user finances were checked and the amounts balanced. It is recommended that two signatures reflect balance checks at intervals and a numbered page book is record to minimise any opportunity to abuse service Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 17 users’ finances. One service user manages their finances but a more detailed record is needed to reflect how risk from abuse is minimised and this is appropriate to the individual’s needs. Staff must remember that whilst they are promoting independence that they also have to observe their duty of care. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome is poor. There are several outstanding maintenance issues which impact upon the quality of the environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home décor reflects the choices and personalities of the service users. There are several large cracks in various areas of the home that are currently Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 19 being investigated but this has been ongoing for several months. The appearance of the cracks has impeded any redecoration and there is evidence of previous light fittings, shelves and smoke detectors which have not been repaired. Although clean the décor is looking weary in places and a timeframe of completion of works is required. The cracks occur under electric supplies and this was evident under the wiring of an extractor fan in a bathroom. A lock on a bathroom door is broken and requires repair. The electrics must be checked to ensure safety whilst there are concerns about the structure of the house. It is recommended that there are no future admissions until works are completed. The only exception to the cleanliness was the hygiene of an assisted bath that had noticeable build up of bath products upon the frame and requires attention. The dishwasher was broken on the day of inspection but a maintenance visit was expected. Although there is sufficient provision for the numbers of service users the downstairs toilet is not working and less mobile service users have to travel upstairs to use the toilet. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 Quality in this outcome is good with the exception of poor recruitment documents. Staff are trained and receive a comprehensive induction. Service users safety is not assured as recruitment checks are incomplete. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels currently meet the needs of service users and the numbers have been reduced whilst the home is not at full capacity. A new member of staff had commenced their induction programme under the Learning Disability Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 21 Award Framework (LDAF) and was being supporting to complete each part of the induction and foundation. Regular training occurs and staff have recently completed a training day learning how to deal with epilepsy. Staff are able to identify their individual training needs in supervision sessions with the manager and deputy manager. There have been few staff changes since the previous occasion where recruitment records were checked. One staff file was inspected but was found to be incomplete: References were available but identified gaps in work history which could not be compared to the application form as none was present. There was no evidence that a Criminal Record Bureau (CRB) check or Protection of Vulnerable Adults (POVA) check had been conducted. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome is poor. A registered manager is not in post. The health and safety of service users could be better assured. This judgement has been made using available evidence including a visit to this service. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 23 EVIDENCE: Although several attempts have been made to recruit, the home is still without a registered manager and an acting manager has been in post for over a year. The deputy manager is acting manager – service users and staff confirmed that they were approachable and that they felt their concerns were listened to and acted upon. A quality assurance system has been devised and this will provide a picture of service users’ and relatives’ satisfaction with the home and company. It has yet to be implemented and on the day of inspection was not available in a format suitable for service users. The requirement to develop an established quality assurance programme will remain in place until actioned. Two service users’ finances were checked and found to be in good order. A recommendation has been made to implement a double signature system to better safeguard service users and staff. The health and safety of service users is generally well observed but some improvements are needed. Fire checks do not reflect that emergency lighting checks are being carried out. There is no risk assessment to reflect that the safety of service users has been reviewed whilst the cracks to the building are being investigated. A recommendation has been made to fit a suitable device to the staff sleep in room to enable the door to remain open or ajar. During the inspection the Insurance certificate displayed had expired and this must be addressed. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 1 38 3 39 2 40 3 41 2 42 2 43 2 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Berrywood Score 3 2 2 X DS0000019290.V323135.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14 12 Requirement Timescale for action 31/01/07 YA6 YA19 3. YA20 13(2) Service users must be formally notified that the home is able to meet their needs. Care plans must adequately 28/02/07 explain how identified needs are monitored, managed and met e.g. epilepsy, diabetes, self medication, money management. These examples are illustrations and not an exhaustive list. Medication must be stored at the 31/12/06 correct temperature and records kept to reflect this is occurring. Handwritten instructions must be signed. Written evidence must reflect to reflect how competence is assured and reviewed. Records must reflect how amounts of medication are checked and service user safety is assured. A record of complaints made and action taken must be kept. A formalised complaints process must be implemented. The financial system used must adequately ensure the protection DS0000019290.V323135.R01.S.doc 4. YA22 22 31/01/07 5. YA23 13(6) 31/12/06 Page 26 Berrywood Version 5.2 6. 7. 8. YA24 YA30 YA34 23 23 19(1)Sc2 17(2)Sc4( 6) of service users from abuse. A timeframe of completion of works must be available to service users and staff. The assisted bath frame must be cleaned. All required information for each member of staff must be kept in the home, including evidence of a satisfactory CRB check. This requirement was made at the previous inspection. Employment gaps must be explored. A manager must be registered with the Commission for Social Care Inspection. Although a quality assurance programme has been devised it is yet to be implemented. The previous requirement therefore remains in place. 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. Monthly emergency lighting checks must be conducted. Risk assessments must be completed to reflect any impact upon service users regarding structural investigations. A valid Insurance certificate must be displayed. 31/01/07 31/12/06 31/12/06 9. 10. YA37 YA39 8 24 28/02/07 28/02/07 11. YA42 13(4) 31/12/06 12. YA43 24 31/12/06 Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 27 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 YA1 Good Practice Recommendations The homes licence agreement and statement of purpose should be produced in a format that can be understood by the residents. They should also contain all the information specified in the National Minimum Standards. The licence agreement should state the room to be occupied and the fees charged for each resident. The recommendation pertaining to service users’ licence agreements has been repeated from the previous inspection reports. 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. 3. 4. 5. YA24 YA41 YA42 In light of the structural investigations being carried out no further service users should be admitted to the home until repairs are completed and the issues are resolved. Financial records should be double signed to ensure service users and staff are safeguarded. A safe device to enable staff to keep the sleep-in room door open or ajar should be fitted. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Berrywood DS0000019290.V323135.R01.S.doc Version 5.2 Page 29 - 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!