Inspection on 06/08/08 for Berrywood Lodge

This inspection was carried out on 6th August 2008.

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 no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berrywood Lodge 06/07/09

Berrywood Lodge 04/02/09

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 19/12/2008.

CARE HOME ADULTS 18-65 Berrywood Lodge 27-33 Berrywood Road Duston Northampton Northants NN5 6XA Lead Inspector Ansuya Chudasama Unannounced Inspection 6th August 2008 09:00 Berrywood Lodge DS0000067749.V369860.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.V369860.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.V369860.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.V369860.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. 29th December 2006 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. The home is located in the Duston area of Northampton and has a bus service to the town centre. The home has been extended to operate as two distinct facilities under one registration. Therefore each side of the home has its own lounge, dining, laundry and kitchen facilities as well as separate staff offices; and the garden area has been separated to enable service users to operate in two user groups, although there is the option of combining as one if required. The providers anticipate a maximum of 17 service users under the Mental Disorder category, and a maximum of 13 service users under the Learning Disability category. The 17 service users under the MD category will use the existing refurbished bedrooms. The number of bedrooms in total is now 30; there are no longer double bedrooms. Two of the larger bedrooms have been converted into ‘independent units’ with the view to supporting transition between care and independent living. These units have their own bathing facilities and kitchen facilities. The kitchen facilities have been created to ensure that the only cooking facilities that can be used are those the service user has been risk assessed as being able to use. The new facility has been furnished and decorated to a good standard. New furniture has replaced worn furniture in the existing lounges, and the quality of Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 5 furnishing and fittings in the new dining rooms and lounges is good. There is sufficient space in the communal areas to meet the space standards for communal areas. The new bedrooms have been furnished to a good standard. All bedrooms have TV points but there are no telephone points – assurance was given that if the service user wanted a telephone point, an engineer would be called to do so. The conversion has improved access to people with disabilities, and there is now access to the ground floor of the home. A wet room has been created on the ground floor to support the cleansing of service users who have more mobility problems. The garden area has been improved, with a mixture of patio and laid lawn. The garden is secure, and the manager is looking at introducing areas of the garden for service users to grow their own vegetables/herbs, and is looking at whether it would be appropriate to have chickens in the garden for service users to care for. At the time of the inspection the works in the home had not been completed. The home was running behind schedule of the date the completion date was to take place. The following fees were provided as being current at the time the preinspection questionnaire was submitted on 29 December 2006: Low risk £350 - £500 per week. Medium risk £500 - £750. High Risk £750 - £1500. The fees include personal care, accommodation, meals and laundry. Service users 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.V369860.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This home has 0 star rating and this means that the people using the service receive a poor service. We inspected the home on the 6th of August 2008. This was because concerns were raised about how the home was managing the needs of the residents living in the home. At the last Annual Service Review in March 2008 concerns were raised about the care being provided by the home. In early 2007, the registered manager of the home resigned, and an acting manager came in to manage the home. After a complaint was made and the provider (owner) went to the service to look into the complaint, the acting manager resigned. There were then concerns raised about the acting manager’s behaviour in the home, and the effect on people living in the home. The area manager of the company that owns the home came in to manage the home for a while. The home has a new manager in post. We were unable to speak to the staff at the inspection due to the staff being very busy and the people living in the home wanted to speak to the inspector. The inspector had to speak to the staff after the inspection. We spoke to the last staff on the 20th of August 2008. We talked to many of the people using the service, and looked at information about policies and procedures, which tells the staff how to do things in the home. We looked at the training staff did to look after the people living in the home. We looked at information about some of the people living in the home to find out how their needs are being met by the home. This is called case tracking. We watched how the people living in the home and staff got along together. What the service does well: People living in the home say: • • • • • • • • They visited the home with family or a social worker before they moved in the home ‘Its ok living here’ ‘its not too bad’ ‘food is good’ We have takeaways I like the staff ‘I enjoy going to work’ ‘staff give me my medication’ Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 7 The staff spoken to stated that: • They enjoyed working at the home • They go on training • They are committed to their work • They have staff meetings • Most say the manager is supportive What has improved since the last inspection? What they could do better: The home should ensure that: • • People using the service are involved in their care plans and they are updated after having a review for people living in the home to reflect accurate care intervention required Ensure that the safe guarding team of social services are informed of any incidents that are safeguarding of vulnerable adults and arrangements must be made to ensure safeguarding referrals are made when incidents occur that adversely affects the health and wellbeing of people living in the home. Structured activities must be undertaken to ensure that satisfactory stimulation and motivation is gained for all people living in the home. Ensure that there are enough staff on duty to meet the needs of all the people living in the home all of the time and have enough staff so all the people in the home can do activities and go out The people living in the home needs to know that they can be confident that no one other than staff sees or hears personal information about them. • • • Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 8 • • • • • • • • • • • • Ensure that advocates are involved in helping people living in the home to make decisions about their care and living in the home Provide person centred planning to meet the needs of people living in the home. Ensure that Incidents/accident forms are sent to CSCI under regulation 37 of the Care Standards Act Undertake regulation 26 visits Involve the people living in the home in the preparation of meals Provide staff with structured induction Management must not borrow money from people using the service without their permission Risk assessments for the building must be kept in the home Provide staff supervision to monitor their practice Provide health action plans for people living in the home Provide a quality assurance system that monitors the views of the people living in the home and staff, and meets the regulation Ensure staff are provided with the training they need to meet the needs of the people living in the home 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.V369860.R01.S.doc Version 5.2 Page 9 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.V369860.R01.S.doc Version 5.2 Page 10 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): 1,2,4 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The service encourages potential people wanting to come to the home to visit the home prior to making a decision to stay EVIDENCE: We were given a copy of the statement of purpose and a service user guide. The service user guide needs reviewing to ensure all the information stated in the standard is included in the document. It also needs to be provided in a format that all the people living in the home can understand. The information in the statement of purpose about making a complaint needs to state the procedures of the complaint with time scales and the address for the Commission for Social Care Inspection is incorrect. Information about social services contact details also needs to be recorded in the guide. All the people living in the home had visited the home with either their family or with their social worker before they decided to stay at the home. The home Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 11 did not undertake their own needs assessments of people coming to the home. There was evidence of information and basic care plan being provided by the funding authority. All the information discussed in the needs assessment was not available in this care planning document. Information read about one of the people living in the home showed that at their previous placement the person was involved with meal preparation, and domestic work. The care plan showed that this person was not undertaking these chores at the home. This was discussed with the managers who stated that the home was going to undertake their own needs assessments of people coming to the home. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 12 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): 6,7,9,10 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People using the service have care plans but these need developing to ensure that the person’s personal goals and changing needs are reflected to meet their individual needs. EVIDENCE: Most of the people spoken to stated that they had not seen their care plans. One person said that their key worker did the care plan and they were not involved. They also did not have a copy of the care plan. The files of the people living in the home needed to be better organised as information was difficult to follow. The files seen had basic care planning Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 13 documents. The care plans were not being reviewed on a six monthly basis or as and when changes occurred. The plans did not state who had been involved in the process and did not state who had completed the care plans. The care planning documents did not explain in detail how a person goal was to be achieved. For example one person’s file stated that the person was to be assisted to manage their finances but it did not explain how this goal was to be achieved. There was also no information in the care plan about how a person’s physical aggression was to be managed. One person stated that they used to draw their own money but because they took too much out, the staff now take the money out for them. The home had not put in an action plan of how the person was to be supported to manage their money. There was information on personal care and some risk assessments had been undertaken but the people living in the home were not involved in understanding their risk assessments. We were told that service users confidentiality was not always maintained. It was said that the people using the service overheard staff talking about them. The home did not have person centred planning (PCP) Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16,17 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Some of the people living in the home are not given the opportunity to take part in a variety of activities both within the home and in the community. EVIDENCE: One person living in the home said that ‘its ok’ living in the home, and another person said that ‘its not too bad’, and the ‘food is nice’. We were told that the staff choose the menus. Staff told us that all the people living in the home are asked what meals they like and the staff choose the meal for the day. The Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 15 people living in the home should be encouraged to choose the meals. There were people who said that some staff knocked on their door before entering and some said that staff did not do this. We were informed that the people living in the home had a ‘residents meeting in March 08’ where it was stated that the people living in the home wanted takeaway food. This was observed on the day of the inspection when people had take away pizzas. It was observed that staff on duty do the cooking in the home at present. We were informed that a chef has been employed and this person will be cooking with the people using the service. The people living in the home spoken to stated that they did not get involved with cooking meals but wanted to get involved with this. One person stated that they watched television and are ‘bored’ at home and had not been out lately. It was also stated that the staff stay in the office a lot and do not spend time with them. One person’s file showed that they went to industrial rehabilitation workshop three times a week. One person stated that they worked in a charity shop and enjoyed this. We were also told that when a person living in the home is told to do some thing by staff and they do not do it, they said the ‘staff shout at me’. Several people told us that they want to be taken out but no staff were available to take them out. It was said that some people did not go out much at all. During the Easter period the home had a party and families were involved. Some of the people stated that their family visited them or they visited them at home. The manager said that she had bought activity games. We were told that people living in the home were referred by pet names and both staff and the people using the service confirmed this. This was discussed with the manager and explained that this practice was not acceptable. People living in the home should be called by their preferred name, which should be recorded in their files. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 16 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): 18,19,20 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The health care needs of the people being cared for are met adequately, although there are gaps in the information staff have an understanding of people’s needs. EVIDENCE: There was information on personal care needs in the care planning documents. Information read in one persons care plan stated that the person was aggressive to staff and people living in the home. But there were no guidelines for how this behaviour was to be managed by staff and to ensure all staff provided a consistency of approach. The staff spoken to had not seen any guidelines for managing behaviours. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 17 One person living in the home was observed sitting and sleeping in their reclining chair and during the inspection we did not observe any interaction or activity being undertaken with staff. We were informed that the person was only recently provided the reclining chair. It was stated that the person should be changed with another member of staff every two hours, but this was not observed on the day of the inspection. We were told that two staff have to attend to the persons personal care needs as identified in their assessment, but it was stated that one member of staff has done this by themselves. We were also told that appointments had to be cancelled because of being short of staff. There was evidence to show that health professionals were involved with the people living in the home that we case tracked. The home did not have health action plans for the people being cared for. The section on mental health was not completed fully. The medication records inspected showed that this was being maintained satisfactorily. However the home needs to monitor the temperatures of the medication and they need to have a controlled drug cabinet that meets the regulations. Medication reviews of people living in the home were being carried out. One person’s file showed that they had not signed the form to authorise the staff to administer their medication The people living in the home are able to go to bed when they are ready. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 18 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): 22,23 People who use this service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home does not have robust financial procedures in place to ensure that the finances of the people living in the home are protected. EVIDENCE: The people living in the home said that if they were not happy, they would speak to the staff and the manager. The complaints procedure is not recorded in the statement of purpose or the service user guide. The home needs to provide a copy of the complaints procedure in a format that the people living in the home can understand. One person informed us that they had a fall and they had informed the staff but nothing was done about it. Management were informed that we had received a complaint about the care practices in the home and the complainant also stated that a copy of the letter had been sent to the organisation. However the management informed us that they had not received this letter of complaint. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 19 We were informed that the manager had asked staff to borrow money from one person living in the home without their permission to give to another person living in the home who had no money. It was also said that the manager told staff to borrow cigarettes from one person living in the home to give to another person living in the home because they had no money to buy cigarettes. However the person who had their cigarettes borrowed was not asked their permission. We were told that the manager asked a member of staff to sign in all the gaps where staff had not signed when money was given to the people living in the home. The home was not reporting all regulation 37 notifications and safeguarding of vulnerable adults referrals to the appropriate agencies. All the staff spoken to had received training on the safeguarding of vulnerable adults procedure. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 20 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): 24,30 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The improvements to the home have made the home a better place to live however the management of the building works caused some people to be unsettled. EVIDENCE: The home has been extended to operate as two distinct facilities under one registration. Each side of the home has its own lounge, dining, laundry and kitchen facilities as well as separate staff offices; and the garden area has been Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 21 separated to enable service users to operate in two user groups, although there is the option of combining as one if required. We were told that the home could accommodate a maximum of 17 service users under the Mental Disorder category, and a maximum of 13 service users under the Learning Disability category. The 17 service users under the MD category will use the existing refurbished bedrooms. The number of bedrooms in total is now 30; there are no longer double bedrooms. Two of the larger bedrooms have been converted into ‘independent units’ with the view to supporting transition between care and independent living. These units have their own bathing facilities and kitchen facilities. The kitchen facilities have been created to ensure that the only cooking facilities that can be used are those the service user has been risk assessed as being able to use. The extended facility has met the standard of one bathing/shower facility for two service users, and some of the bedrooms have en-suite facilities. The new facility has been furnished and decorated to a good standard. New furniture has replaced worn furniture in the existing lounges, and the quality of furnishing and fittings in the new dining rooms and lounges is good. There is sufficient space in the communal areas to meet the space standards for communal areas. The new bedrooms have been furnished to a good standard. All bedrooms have TV points but there are no telephone points – assurance was given that if the service user wanted a telephone point, an engineer would be called to do so. The conversion has improved access to people with disabilities, and there is now access to the ground floor of the home. A wet room has been created on the ground floor to support the cleansing of service users who have more mobility problems. The garden area has been improved, with a mixture of patio and laid lawn. The garden is secure, and the manager is looking at introducing areas of the garden for service users to grow their own vegetables/herbs, and is looking at whether it would be appropriate to have chickens in the garden for service users to care for. The home was clean and tidy on the day of the inspection. A tour of the home showed that a path in the middle of the two homes looked unsafe. It was said that the entrance was going to be used as an emergency. A risk assessment needs to be undertaken for this area. The refurbishment should have been completed in July 08 but this had not happened. We were informed that the planning had not been done well. One person in the home had chosen their curtains but the rest were chosen by the home. It was also Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 22 said that the building works had an effect on the people living in the home. This is because some of them had to move bedrooms 2 to 3 times. We were told that some of the people were disappointed because they had moved from an old room to a new room and then they had to move back to the old room. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 23 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): 32,33,34,35 People who use this service experience adequate quality outcomes in this area.” We have made this judgment using a range of evidence, including a visit to this service. The home does not have adequate staff on duty to meet the needs of the people living in the home. EVIDENCE: The staff spoken to state that the home was very short staffed and this was confirmed by talking to people living in the home. The home had two care staff on duty per shift and they had to do the cooking, give out medication, do the administration and meet the needs of the people living in the home. This was also taking into account the building works happening in the home Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 24 The manager stated that two senior staff were joining the team at the end of the month and a chef was employed to do the cooking. It was said that the staffing structure will consist of team leaders in each area of the home, and the team leader will have more specialist knowledge of the service user group in that area. A cleaner was also being employed by the home. Staff spoken to and files looked at evidenced that there were no records of staff induction. The staff spoken to confirmed that they did not have an induction when they started work at the home. It was also stated that staff were not provided with regular supervision. We were informed that the organisation has now got the skills for care staff induction and this will be used with the new staff. The staff recruitment files inspected showed that the organisation was undertaking the right procedures when employing staff. However one member of staff’s file did not have references, however we were told that the person’s references had been obtained but management was unable to find them. The staff contracts seen in their files were some times not signed or dated. We were told that the working relationships with some staff and the people living in the home were seen as being too friendly. The manager is advised to discuss professional boundaries with staff. Most of the staff spoken to had not done any training and did not have an understanding on Autism. We were told that some had not done any training on first aid, food hygiene, Epilepsy, communication, health and safety training, and dementia. We were also told that the home had inexperienced staff who did not understand the needs of the people living in the home. It was said that there are staff who are afraid to deal with people using the service who are aggressive and they need more support. The staff spoken to enjoyed working with the people living in the home, and were committed to their work. We were told that the staff team do the best job they can within the situation and the organisation needs to increase staffing levels and the level of experience of the staff. Team building training days were asked for by staff to improve staff morale and a way forward to working as a team. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 25 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): 37,39,42 People who use this service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Management systems are not sufficient to ensure an acceptable level of service is provided for people living in the home. EVIDENCE: The manager had been managing the home since January 2008 and was recently registered as the manager of the home. The manager trained as a mental health nurse and has worked in all areas of psychiatry. She has also worked as a sheltered housing manager. The manager needs to undertake NVQ level 4 in management Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 26 Some staff informed us that the manager was making good changes. Staff meetings were being held and the manager had started to undertake supervisions. The manager was finding it difficult to manage the two units with the building works going on, and the home being short of staff. Discussion with the manager showed that she knows what changes are needed to be able to manage the unit efficiently. At present the home has two staff and the manager helps out with day-to-day chores, this has meant that she has not been able to manage her administrative duties. It was said that when the two senior staff start, the two people will be responsible for each unit and the manager will be able to monitor and manage the unit. The manager needs to be better supported by her senior management. The home had not been completing regulation 37 notifications for incidents that were occurring at the home. The manager was aware of this and has started doing these. The staff must also ensure that staff completes accident/incident forms when a person living in the home informs them that they have had a fall. The home had not undertaken any fire drills due to building works going on in the home. The fire alarm and emergency lighting were not being done on a regular basis. We were informed that the Fire officer was visiting the home tomorrow. The manager was asked to send the CSCI the out come of the visit but this was not received at the time of writing this report. No regulation 26 visits had been carried out since 27th of April 08 and this was discussed with senior management who is responsible for this visit. It was said that these visits were on the person’s computer but they were not able to print these copies from the homes computer. The senior manager was asked to forward these copies to the CSCI at the time of writing this report this information was not received. The home did not have a first aid person on each shift. The manager told us that four staff were going on this training soon. The risk assessments were not available for the building. We were told that these were kept with the person in charge of the building work and the person had gone home. We asked these to be send to the CSCI but these had not been received at the time of writing this report. The home did not have a quality assurance system in place or an annual development plan. Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 27 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 2 2 2 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 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 2 2 X 2 1 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 2 1 2 2 2 2 1 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 1 X X 2 X Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 28 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 Standard YA2 Regulation 14 Requirement Assessments of peoples needs must be completed in full and linked to the care plans to make sure that their needs are met in full. The care plan must state how the service users aspirations and goals will be achieved and describes any restrictions on choice and freedom; the plan should be drawn up with the involvement of the service user and their representative or an advocate. Confidentiality of people living in the home must be maintained 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. There must be guidelines in how to manage the challenging behaviours of people living in the home There must be adequate number of staff on duty to ensure that service users appointments are not cancelled and their health DS0000067749.V369860.R01.S.doc Timescale for action 30/11/08 2 YA6 15 30/11/08 3 4 YA10 YA12 12(4)(a), 12,16 30/09/08 30/11/08 5 YA19 12 30/10/08 6 YA19 18 30/10/08 Berrywood Lodge Version 5.2 Page 29 needs are met. 7 YA23 17 Management must not ask staff to sign the gaps that have not been signed when giving out service users money Management must not borrow money or cigarettes from service users without their permission All allegations and incidents of abuse must be reported to the Local Authority Safe Guarding team to ensure the safety and protection of service users. A risk assessment for the path in the middle of the two homes must be carried out to protect the people from any accidents. Ensure that all the staff receive training in autism, dementia, food hygiene, epilepsy, health and safety, and infection control Staffing levels must be reviewed to ensure there are sufficient staff at all times to meet the service users assessed needs. Staff must be provided with induction and foundation training to meet the needs of the people being cared for. A system for establishing and maintaining the quality of care, which includes consultation with service users and their representatives, must be implemented. The organisation must carry out regulation 26 visits on a monthly basis to monitor the home Staff must ensure that if a service user needs two people to meet their personal care needs, this is happening to ensure the health and safety of both the staff and the person being cared DS0000067749.V369860.R01.S.doc 30/10/08 8 9 YA23 YA23 17,12 13 30/10/08 30/10/08 10 YA24 12 30/11/08 11 YA32 18 30/11/08 12 YA33 18 (1) (a) 30/10/08 13 YA35 18 30/10/08 14 YA39 24 30/11/08 15 16 YA39 YA42 26 13 30/10/08 30/10/08 Berrywood Lodge Version 5.2 Page 30 for. 17 18 YA42 YA42 13 37,17 Fire alarm testing and 30/10/08 emergency lighting must be carried out regularly All incidents and accidents must 30/10/08 be recorded in the home and the CSCI must be informed of this by sending a regulation 37 Notification. The risk assessments for the 30/10/08 building must be available in the home and for inspection purposes 19 YA42 13 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 YA7 Good Practice Recommendations The ways in which service users rights to make decisions about their lives are supported should be reviewed. The range of decisions available to service users and the capacity of individual service users to make their decisions, should be looked at with a view to improving this aspect of their care. Service users should actively be supported to help plan, prepare and serve meals in the home. 2 YA17 Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 31 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. Extracts may not be used or reproduced without the express permission of CSCI Berrywood Lodge DS0000067749.V369860.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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