Inspection on 04/02/09 for Berrywood Lodge

This inspection was carried out on 4th February 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Berrywood Lodge 06/07/09

Berrywood Lodge 06/08/08

Berrywood Lodge 29/12/06

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.

CARE HOME ADULTS 18-65 Berrywood Lodge 27-33 Berrywood Road Duston Northampton Northants NN5 6XA Lead Inspector Ann Wiseman Unannounced Inspection 4th February 2009 08:30 Berrywood Lodge DS0000067749.V374335.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 Lodge DS0000067749.V374335.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 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 Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berrywood Lodge Address 27-33 Berrywood Road Duston Northampton Northants NN5 6XA 01604 751676 01604 583098 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) www.minstercaregroup.co.uk Minster Pathways Limited Katherine McGarry Care Home 30 Category(ies) of Learning disability (30), Mental disorder, registration, with number excluding learning disability or dementia (30) of places Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are: Learning disability - Code LD Mental disorder - Code MD The maximum number of service users who can be accommodated is 30. 1st December 2008 2. Date of last inspection Brief Description of the Service: Berrywood lodge is owned by a company called Minster Pathways Ltd who own other homes accommodating a similar client group. This home is located in the Duston area of Northampton and has a bus service to the town centre. The home was extended with the expectation that it would operate as two distinct facilities under one registration. So each side of the home has its own lounge, dining, laundry and kitchen facilities as well as separate staff offices; and the garden area can be separated to enable people living in the home to live in two smaller groups. This plan was not instigated and the home remains as one big unit. Before the refurbishment there was two double bedrooms, they have been made into single rooms and the home now has thirty single rooms. Two of the larger bedrooms have been converted into independent living units with the view to supporting transition between care and independent living. These units similar to studio flats and have their own bathing and kitchen facilities. Only people who have been assessed as being able to safely use the cooking equipment with be able to live in the independent living units. The conversion has improved access to people with disabilities, and there is now access to the most of the ground floor of the home, there are still some level differences with one or two steps between them. The fees differ depending on the level of support needed and range from £300 to £1500. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 5 The fees include personal care, accommodation, meals and laundry. People who wish to make arrangements to visit the hairdresser, barber; purchase magazines; newspapers and toiletries do so from their own resources. This also applies should they wish to access private chiropody and other private services. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection; we arrived at 8.30am in the morning and left soon after 4pm. The manager was on annual leave on the day of our visit but the service manager and the operations manager where at the home and facilitated the inspection, which was done in an open and helpful manner. During the day we had a look around the home and talked to some of the people living there and some of the staff. We were able to observe the interaction between the staff and the people who where at home. We looked at information belonging to three people and the available information of three of the staff. We also assessed some of the homes policies and procedures and sampled a random selection of the health and safety files and records. Before the inspection we asked the previous manager to complete the Annual Quality Assurance Assessment (AQAA) we had sent her. The AQAA is a selfassessment that focuses on how well outcomes are being met for people living in the home. It also gives us some numerical information about the service. The AQAA was not returned within the requested timescales, despite a reminder letter being sent. There was a change of manager about the time we asked for the AQAA so it may have been overlooked because of the changes. However, it is important that services comply with our request to return the document on time. It is an offence under Regulation 24 and 43 of the Care Homes Regulations 2001 not to fill in and send to us the information we ask for in the AQAA part 1 - self-assessment when we ask for it. If the home does not send us this information they may be committing an offence under Section 31 (9) of the Care Standards Act 2000 and may be prosecuted. The last key Inspection for this home was in August 2008, in December we received information from someone who wanted to remain anonymous that gave us reason to believe that the home was not using the required procedures to recruit staff and were not carrying out proper safety checks before new staff started work. We decided to carry out a random inspection so we could check the validity of the information given to us. The outcome of the random inspection will be covered in this report. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 8 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 Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 4 were examined on this occasion. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People thinking of moving into Berrywood Lodge are offered enough information to enable them to make an informed choice about moving into the home and everyones needs are assessed before they move in. EVIDENCE: The homes statement of purpose has been updated by the new manager since December and is available in a clear and comprehensive format. The style is generic to the company and consideration should be given to making them more individual to the home. We examined three peoples files during this inspection and they contained assessments and care plans, that had been derived from the assessments, that identify peoples aspirations and needs. It is the companies policy that people are able to “test drive” the home. The service manager confirmed that people thinking of moving in are given the opportunity to visit the home and the placement is reviewed before they make a final decision to stay. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, 9 and 10 were examined on this occasion. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People living in this home have care plans and are assisted to make decisions for themselves and are consulted about the way they want to live. People are enabled, through risk assessments, to take some risks as part of an independent lifestyle. Staff are trained to respect confidences and to handle personal information in a way that will maintain confidentiality. EVIDENCE: Three care plans were examined, they reflected the needs and aspirations of the person involved. They have been updated and remodelled since the last inspection so that they are more person centred and have been reviewed. One person’s care plan that we looked at highlighted areas in their life when they can display challenging behaviour, but there were no guidelines in place on how to manage these difficult situations. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 11 It was required in the previous report that anyone living in the house who has challenging behaviour must have guidelines in place that tell staff how the behaviours manifested themselves, what situations are likely to trigger them and what interventions should be used to defuse the situation. The requirement will be restated. People who live in the home make decisions about what happens and the things they do. They are supported to choose the menus and house meetings are held where everyone gets a chance to comment about how the house is run. A poster was on the wall advertising the date and time of the next house meeting. There were risk assessments on file that have been developed to minimise the risk of harm in all of peoples every day activities. We saw in staff files that their induction training includes keeping confidences and private information is stored in a locked cupboard in the office and is not left lying around in communal areas. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 and 17 were examined on this occasion. People who use the service receive Adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. We are assured that people are able to take part in appropriate activities and are part of the local community, but there is no formal activity plan and they are not recorded. Friends and family are welcomed in the home and people told us that their rights and responsibilities are recognized and upheld. Food offered is varied and in ample portions. EVIDENCE: While we were at the home some people had gone out to the day centre, which is within walking distance. Others choose to stay at home or carry out other independent activities including shopping for every day needs, listening to music in a small lounge or watching the television in another. One person has been supported to sell sweets and drinks to others in the home, which have been purchased out of house funds. The “tuck shop” is a venture that originated as a wish in someone’s person centred planning meeting and it’s opening has proved popular amongst the people living in the home. People Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 13 who need to be escorted when they go out are given opportunities to go shopping and eating out. Other activities such as outings to the cinema, theatre and trips to local parks and places of interest are organised in an informal way and they are recorded in people’s daily records. While we were at the home someone was supported to go out to buy some items for their bedroom. However, the previous key inspection required that a planned, varied programme of activities should be developed that took account of everyone’s wishes, needs and capabilities so that all people could be engaged in fulfilling and meaningful activities. This has not been complied with and the requirement will be restated. The activities programme must include a central recording system that enables records to be kept of what activities are offered to people, who declines to go and the reasons, which ones go ahead or how well received they were. This will enable the manager to audit what activities are in place, their outcome, plan for the future and to monitor activity. We were told by the service manager that those people who have family are helped to keep in touch and we saw visitors come and go during our visit and there was evidence in people’s files that they have visits from family and friends. Parties are held on special occasions and family and friends are invited. Interaction between people living in the home and the staff was observed to be open, friendly and respectful. While we toured the building staff were seen to always knock on people’s door before entering and people were asked if we could come in before we entered the bedrooms. People are responsible for keeping their rooms tidy and for doing their own laundry, staff support those that need assistance. We observed two meals while we were at the home, lunch and tea. We noticed some food hygiene infringements in the kitchen that will be discussed later in this report. The menus are devised with the assistance from people who make suggestions during the house meetings. During the visit the food was being prepared by a staff member as there was no chef in post, one has been appointed and will start work when his safeguarding checks have been completed. The food on offer looked appetising and the portion size was ample. The tables are set and cleared away by people living in the home. Staff need to take better care that they support people to clean the tables properly as there was dried food on the tables and chairs. The tables were set very early and several people had begun to sit at the table and wait for the meal 45 minutes before the set mealtime, one person was sitting with their head on the table appearing to be asleep while waiting at both meals. This could indicate that people are not motivated or engaged enough to keep themselves busy and that mealtimes are the only eagerly anticipated activities in the home during the day. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 14 Once a table has been set it may indicate that the meal is almost ready so people are prompted to sit at the table. Setting the table should be delayed until just before the food is ready. There is one kitchen that is not in use; it could be used as a good opportunity for people to be supported to prepare and cook meals and snacks for themselves in a less busy environment. The home have recently started using the new dinning room, this is good because it is close to the lounge people tend to use more often, so it is easier to get to for people who find walking difficult. It is a light and airy room with good quality furniture and makes an attractive place to eat. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were judged during this visit. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. This home records peoples personal care needs in a way that enables them to be supported how they want to be and they have access to doctors and specialist care. Medication is mainly managed properly but there are some areas that need addressing. EVIDENCE: We looked at three care plans and found that, peoples support needs were recorded and they were written in a way that reflected peoples personal preferences. They were reviewed regularly enough to give people an opportunity to change their minds about how they want to receive personal care. We found evidence, in the files we examined, that people have access to medical practitioners as and when they need to, they also get support from specialists such as speech and language therapy, psychology, psychiatric, dentists and opticians. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 16 We examined the medication and its records and found that they were mainly as required. The home has a controlled cabinet on order that will be delivered and fitted in the near future. In the meantime they are using a lockable box, which is stored in the medication cupboard for the controlled drugs they use. One person has Clozapine, which is being stored as a controlled drug. We checked and found that it was recorded as required in a controlled drug book and that the number of tablets was as recorded. Unfortunately the original box that the drug had been dispensed into by the pharmacist had been discarded along with all the required information that the label contained. This goes against the guidance given by the Royal Pharmaceutical Society of Great Britain who recommends that medication should be stored in the original box with the written details printed by the pharmacist as the label contains information required to be there by law. Diazepam, kept to be given to someone only if they can’t sleep, was checked and we found that there were more tablets than the recording sheet said there should be, Co-codomol tablets were not properly recorded either and the quantities were less than the record sheet indicated there should be. The service manager has undertaken to carry out a full audit of the medication and to remind staff to properly check and record medication both when it is delivered and when it is returned. The whole staff team have since undertaken medication training. Several people in the home have medication that is prescribed to be taken when needed (PRN) To ensure that PRN medication is given as intended a specific plan for administration must be recorded in the care plan and ideally kept with the MAR charts. These guidelines should include information on why the medication has been prescribed, how to give it and what interventions should be tried first. There were no PRN medication guidelines with the MAR sheets or included in the care plan. It will be required that they are put in place. Our professional website is available to everyone and contains guidance on many topics including medication. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed during this inspection. People who use the service receive Adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Complaint policies and procedures are in place and we have been told that there have not been any formal complaints, but the complaints book could not be found. People are protected from abuse by staff being properly trained in safeguarding and managing challenging behaviour. More care needs to be taken in the way that peoples money in the home is recorded. EVIDENCE: The home has complaint and safeguarding policies and the complaints procedure is displayed in the home and copies are given to people when they move in. The service manager told us that they had not received any formal complaints recently but was unable to find the complaints log so that we could check that systems are in place to properly record complaints and concerns. We discussed the necessity of using the complaints book to record all concerns raised, no matter how minor they appear so that the manager will be able to audit them and to identify trends. We received an allegation that was made directly to us by someone that wants to remain anonymous, details of which will be outlined later in the report. We asked the responsible person to investigate the allegation, which they did and took appropriate action. We are happy with the outcome. Those involved have been reprimanded and have received redirection. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 18 We examined the way that the home looks after peoples personal money. The money spent is recorded and receipts are kept. Peoples money in the home is stored in individual purses that are locked away in the office for safe storage. We examined some of the purses and found that the amount of cash in two of the purses didn’t corresponded to the totals recorded on the record sheet. The service manager explained that money had been taken out in the morning as spending money when people went to the local shops and that the amount would be amended when the change was returned. It is important that the records are correct at all times so it is required that the recording sheet is reconciled when money is removed from the purse and when the change is returned so that it always reflects the correct balance. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24. 25, 26, 27, 28 and 30 were judged this occasion. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. This home is comfortable and clean. Bedrooms suit peoples needs and lifestyle and there are sufficient bathrooms and toilets. Food hygiene issues need to be addressed in the kitchen and fire safety issues have been addressed since the random inspection. EVIDENCE: The home is a large and rambling building, which gives many opportunities for people to find quiet areas to sit and keep their own company if the want to. The new part of the building is freshly decorated and furnished to a good standard in a domestic style, there are attractive pictures on the walls and there are plans to bring the rest of the home to the same standard, at the moment the original part is in need of redecoration and is less homely. There is a large, newly laid out garden that will be further developed to include grassed areas and a vegetable plot. It is accessible to everyone. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 20 All of the communal rooms are clean and hygienic and bedrooms are individual and reflect the personality of the people who occupy them. There are sufficient bathrooms and toilets to meet peoples needs and some have been fitted with equipment to maximise independence. Two of the bedrooms have been designed so that people will be able to develop their independent living skills. They are large rooms and set out in the style of a bed-sit with a small kitchenette and bathroom. During the random inspection that was carried out in December 2008 we saw that the fire notices that had been taken down during the building work had not been replaced. This meant that the fire exits and escape routes were not marked. We noted, while we were at the home for this key inspection, that all of the required fire signs have been put in place, and fire extinguishers that were not attached to the wall have been dealt with. Also some of the fire doors to bedrooms and other rooms were found not to close completely when the door was released. They have not been all been repaired so the requirement will be restated. To stop people using doorstops to keep fire doors open in communal areas mechanical doorstops have been bought that will release the doors automatically when the fire alarm is sounded and we were assured that they will be fitted within a few days of the inspection. When we inspected the kitchen we found several food hygiene infringements. We have discussed the issues with the service manager and she is aware of what needs to be done. The home haven’t had a chef for some time and no one had taken on the responsibility of making sure that hygiene standards are upheld in the kitchen. A new chef has been appointed and will begin work once his safeguarding checks have been completed. He will be made aware that maintaining standards will be part of his responsibilities. It will be required that all staff who prepare food must undertake refresher food hygiene courses. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 34, 35 and 36 were assessed during this visit. People who use the service receive Good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staff are aware of their roles and responsibilities and are qualified. The home has recruitment policies and procedures in place that are being followed. Training is in place and staff are receiving supervision. EVIDENCE: During the random inspection carried out on 1st December 2008, because of information we had received, we checked all of the staff files to make sure that all the companies policies and procedures were followed and that they contained all the information required under the Care Homes Regulations 2001. While checking the staff files it was found that two staff members had started work prior to Criminal Records Bureau checks being completed. One of the people was the new manager. We were not able to see her file as it has been kept at the company’s area office, however when asked she told us that her references had been returned and so had the poVAfirst check but not her CRB. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 22 Our guidance on this issue is: • In exceptional circumstances the Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 allow new members of staff to begin work before a CRB disclosure has arrived, using the ‘PoVAFirst’ system. Service providers should carefully check the regulations covering recruitment and how they have been amended, to see how they apply to their service. Care staff who have applied to work with adults and… o have received a clear POVAFirst check; and o have received the induction set out in the regulations for each kind of service; and o where people who use the service would be at risk if the applicant were not to start work before the return of a full CRB disclosure; …can begin work under supervision in a care home. Care home workers can only work unsupervised when a full and satisfactory CRB and POVA check has been received. It was not apparent that people would be at risk if the new manager had waited to take up post until her checks were in place as the area manager was based at Berrywood Lodge and could oversee the home until all the checks are done. The area manager undertook to supervise the new manager until she was cleared to start work. Under no circumstances could the manager be left unsupervised in the home where she may be in contact with the people living there. It is not appropriate for the manager to be supervised by people she may be managing in the future because the balance of power may affect their ability to challenge her authority. The other person without a CRB was the maintenance person. There was a contact at the home signed by him on 17th November 08, but there was no evidence of his application, interview notes, references, poVAFirst or CRB check, nor was there any evidence that the checks have been applied for. Records showed that he had been working at the home for at least two weeks prior to the random inspection; he had carried out fire systems checks and had signed the records. It is apparent that he started working in the home immediately he was appointed without any effort being made to carry out safety checks on him. During the inspection this staff member was seen to have free access to the home and there were several people present who live there. • • Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 23 This was a serious breach of care standard regulations and we required that this person should not work at the home again until his checks were in place. The area manager agreed and confirmed in writing that he would not work in the house again until the proper checks have been done. Following the inspection we asked the responsible person to investigate why staff had been allowed to start work at the home before proper safeguarding checks had been done. The investigation was carried out within our set timescales and we have been assured that the person responsible for the breach has been dealt with appropriately and the situation will not be repeated. We checked three staff files during this inspection and they were found to be in order, they contained all the required information including copies of contracts and job descriptions given to staff so that they were aware of their roles and responsibilities. CRB checks were in place. The staff files we looked at contained evidence that showed staff are offered some training and are qualified. We were told that there hasn’t been many training sessions undertaken over the winter and there was no evidence to show that a previous requirement regarding staff training had been done, but the service manager has assured us that the manager has developed a training matrix for this year and staff will have their training needs assessed during their annual appraisals. The service manager also informed us that the majority of staff either have an NVQ qualification in care or are working towards one. Some of the care staff have finished their NVQ2 and have started working towards NVQ3. The files also showed us that the new manager has begun supervising staff, they contained supervision contracts and records of the meetings. We recommend that all staff within the home, including the manager and any auxiliary staff, should receive formal one-to-one supervision at least six times a year. To ensure that is target is reached the manager should consider developing a supervision plan. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38, 39 and 42 were judged during this inspection. People who use the service receive Adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. This home is moving towards being a well-run establishment with an ethos that is empowering to the people living in it. Previous fire safety issues have been addressed and necessary checks are made and records are kept, but a higher priority needs to be given to food hygiene. EVIDENCE: Since the last key inspection there has been a change of both manager and service manager in this home and support has been given by the company to enable the manager to make a good start on improving the quality of care people receive from the service. A lot of work has been put into complying with the many requirements generated at the previous inspections and the majority have now been completed. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 25 There are still areas that need to be improved, such as the management of medication, people’s monies, environmental health and an improvement in the provision of meaningful activities other than attending a day centre. Every year we ask all services to complete an Annual Quality Assurance Assessment (AQAA), which gives us information about the home and also gives us an indication on how well the home understands people’s needs. We asked the home to complete the AQAA and return it to us in October last year and despite a reminder being sent, we have not received it. It is an offence under Regulation 24 and 43 of the Care Homes Regulations 2001 not to fill in and send to us the information we ask for in the AQAA part 1 - self-assessment when we ask for it, and by not sending us this information the home may be committing an offence under Section 31 (9) of the Care Standards Act 2000 and may be prosecuted. During discussions with the manager and service manger it was apparent that they both had a good understanding of what needs to be done to bring the home up to standard, and both recognise it is a work in progress. Care plans are being reviewed and the introduction of person centred planning is being rolled out, a few had been done at the time of the inspection and the rest will be done in the near future. While concentrating on bringing other areas up to standard, food hygiene in the kitchen has been allowed to lapse. For example food was stored on the floor in the larder and a box of catering size bags of breakfast cereal was stood on the kitchen floor, one of the bags had been opened and was left unsealed and gaping open. The large amount of cereal in the bag was unlikely to be finished quickly and if the home feels it necessary to buy such large quantities they must store the food in airtight containers to keep it fresh and free from contamination. While checking the contents of the fridge we found that a urine sample was being stored there to keep it fresh while it was waiting to be taken to the surgery. As soon as it was bought to the attention of the service manager she had it removed. During the previous inspection we found that Regulation 26 visits were not taking place. Under regulation 26 a member of the organisation other that the person in day-to-day control of the home is expected to carry out a spot checks to make sure the home is functioning properly. They are now done and the reports of the visits showed they are detailed and thorough. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 3 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 3 25 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 2 X Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 27 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 YA12 Regulation 12,16 Requirement A planned varied programme of activities must be developed to meet the needs, capabilities and wishes of all service users to engage them in fulfilling activities. This is a restated requirement. 2 YA19 12 There must be guidelines in how to manage the challenging behaviours of people living in the home This is a restated requirement. 3 YA32 18 Ensure that all the staff receive training in autism, dementia, epilepsy, health and safety, and infection control. This is a restated requirement. 4 YA32 18 Training and guidance must be given to improving staff knowledge of Food Hygiene. Proper provision for the safe storage of food must made, if necessary professional guidance should be sought. Checks must be made on all fire doors to make sure that they close completely on release, this DS0000067749.V374335.R01.S.doc Timescale for action 06/06/09 06/06/09 06/06/09 06/06/09 5 YA42 12 06/06/09 6 YA24 23(4) 06/06/09 Berrywood Lodge Version 5.2 Page 28 should be done as part of the weekly fire system checks and any that don’t must be repaired. This is a restated requirement 7 YA20 13 PRN guidelines must be developed to ensure that PRN medication is given as intended. These guidelines should include information on why the medication has been prescribed, how to give it and what interventions should be tried first. A system must be put in place and ready to use to enable complaints to be recorded in a clear and open way. It will record all issues raised or complaints made by people living in the home or their representtive, also details of any investigation, action taken and outcome. This record must be checked at least every three months by the manager. It is important that the record of peoples money is correct at all times so it is required that the recording sheet is reconciled when money is removed from the purse and when the change is returned so that it always reflects the correct balance. An AQAA must be completed and sent to us because it is an offence under Regulation 24 and 43 of the Care Homes Regulations 2001 not to fill in and send to us the AQAA part 1 self-assessment when we ask for it, and by not sending us this information the home may be committing an offence under Section 31 (9) of the Care Standards Act 2000 and may be prosecuted. 06/06/09 8 YA22 22 06/06/09 9 YA23 17 06/06/09 10 YA37 24 06/06/09 Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 29 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 YA17 Good Practice Recommendations It is recommended that people are discouraged from laying the dinning table too early as it lets people think that the meal is ready and people spend a lot of time sitting at the table waiting for their meal. People should be engaged in other activities so they are distracted and busy and don’t feel they need to sit in the dinning room so long. 2. YA17 People should be actively be supported to help plan, prepare and serve meals, possibly by making better use of the kitchen not in use at the moment. Berrywood Lodge DS0000067749.V374335.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact 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. 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