Inspection on 28/02/07 for Berwick Bridges

This inspection was carried out on 28th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Berwick Bridges 15/01/06

Berwick Bridges 04/08/05

Berwick Bridges 16/02/05

Berwick Bridges 06/10/04

Berwick Bridges 02/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Berwick Bridges 4a Roberts Lodge Tweedmouth Berwick Upon Tweed Northumberland TD15 2YN Lead Inspector Dennis Bradley Key Unannounced Inspection 28 February & 23rd March 2007 15:00p th Berwick Bridges DS0000000617.V295631.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 Berwick Bridges DS0000000617.V295631.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. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berwick Bridges Address 4a Roberts Lodge Tweedmouth Berwick Upon Tweed Northumberland TD15 2YN 01289 - 303173 01289 - 303173 bbt.berwick@btinternet.com 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) Berwick Bridges Limited Mrs J A Murray Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of whom 2 may have an additional physical disability Date of last inspection 15th January 2006 Brief Description of the Service: Berwick Bridges, at 4a Roberts Lodge, provides care and support for up to six individuals with a learning disability. The Home is a purpose built bungalow and is situated in a small residential estate in Tweedmouth, on the outskirts of Berwick upon Tweed. Community facilities are within walking distance and Berwick is only a short drive or bus ride away. The Home has an adapted people carrier and the area is well served by public transport. The accommodation includes six single bedrooms, plus a staff ‘sleep-in’ room, an open plan lounge, dining and kitchen area and a separate utility room. Adequate toilets and bathing/showering facilities are provided. The Home is domestic in character and decorated and furnished to a good standard. There is an enclosed garden/patio area to the side of the building as well as a small car park. The Service is operated by Berwick Bridges Ltd. a voluntary organisation that was set up to provide a service for people with learning disabilities from the local area. Copies of the Home’s Statement of Purpose and this Commission’s inspection reports were available in the Home. The current scale of charges is £567.99 per week. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The first inspection visit to Berwick Bridges was unannounced and started at 15.00pm. The inspection involved two visits to the Home. The inspector met all five of the residents and spoke to a number of staff, including the Manager. Questionnaires were also sent to each resident and their relatives as well as to some of the professionals who have contact with the Home. Four of the residents completed the questionnaire with the support of staff. A response was received from four relatives and a care manager. The Manager had also completed a pre-inspection questionnaire. During the visits to Berwick Bridges the inspector looked around the house and examined a sample of records. He also joined the residents and staff for their evening meal. Two of the residents showed the inspector their bedrooms. The Commission had not been notified of any incidents concerning the Home since the last inspection and it had not received any complaints or allegations about the Home. What the service does well: These are some of the things the service does well: All of the residents spoken to said they liked living at the home. In their response to a questionnaire four residents indicated that staff: ‘always treat them well’ and ‘listened to them and acted on what they said’. One resident said: “I have been here for 10 years and still enjoy living here”. Relatives of four residents confirmed that the home met the needs of their relatives. One relative said: “They all live in a homely environment (and) are all cared for and treated very well”. Another relative said: “My brother is exceptionally well cared for”. All of the relatives confirmed that the home met the different needs of the people who live at Berwick Bridges. The care manager for two people said: “Individual residents (were) always treated with respect and dignity” and, “Care staff provide support to all residents enabling them to make informed choices where possible”. The needs and wishes of each resident had been properly assessed before they moved into the Home. This meant that staff knew about the needs of each person and what care and support they required. Suitable plans of care and risk assessments had been completed for each resident. This meant staff had the information they needed to support each person and keep them safe. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 6 The arrangements for supporting residents to make decisions about their daily lives and preferences were satisfactory. Each person was supported to take appropriate risks as part of the Home’s plans to promote as much independence as possible. Suitable arrangements were in place for people to take part in appropriate activities in line with their needs and preferences. The arrangements for supporting residents to maintain contact with their friends and family were satisfactory. The relationships between staff and residents were good and personal support was provided in such a way as to promote and protect residents’ privacy and dignity. The meals provide by the Home were satisfactory and gave residents a varied, nutritious diet. Suitable plans of support were in place and staff had a good understanding of each resident’s support needs. The arrangements for monitoring and meeting the health care needs of residents were satisfactory. This meant that people received the care and support they needed. The arrangements for the administration and recording of medication were satisfactory and protected the residents. Suitable arrangements were in place for handling complaints and for protecting residents from abuse. There was evidence that residents’ felt they could confide in staff and that their views were listened to. The arrangements for keeping the Home clean and tidy were satisfactory. The standard of the accommodation, décor and furniture and fittings was good and provided residents with a clean and comfortable place to live. There was a competent team of staff who had access to a range of training opportunities. There were arrangements for ensuring staff received training that covered the specific conditions of residents. This meant that people were being cared for by staff who had had training that covered their specific conditions. The manager was suitably qualified and experienced and demonstrated a commitment to provide good quality care and support for the people living at the home. This is important in ensuring that the home is well run. Steps had been taken to keep the residents safe. This meant that residents were, for example, protected from the risks of fire. What has improved since the last inspection? Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 7 A workshop had been held to consult with service users about their wishes in relation to growing older, terminal illness and death. Staff had participated in the workshop. Plans of care for people living at Berwick Bridges were being developed to address each person’s longer term needs. The home’s fire risk assessment specified how often staff should take part in fire drills. New furniture had been provided in the home’s open plan living area and some rooms had been re-decorated. 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. Berwick Bridges DS0000000617.V295631.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 Berwick Bridges DS0000000617.V295631.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area was good This judgement has been made using available evidence including a visit to this service. The needs and wishes of each resident had been properly assessed before they moved into the Home. This meant that staff knew about the needs of each person and what care and support they required. EVIDENCE: There was evidence that, before they moved into the home the needs of each person had been assessed by the professionals involved in their care. The prospective resident and, where appropriate, their families were also involved in this process. All four residents who completed a questionnaire confirmed that they had been asked if they wanted to move into the home. They also confirmed that they had been given enough information about the home to enable them to decide if it would be the right place for them. Pre admission meetings had been held to discuss and agree how each person’s care needs and personal preferences would be met. The Home also carries out its own pre-admission assessment and uses this as the basis of the initial plan of care for the resident. Where necessary, for example as a result of the changing needs of the residents, reassessments had been carried out and care and support had been reviewed. Berwick Bridges DS0000000617.V295631.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Suitable plans of care and risk assessments had been completed for each resident. This meant staff had the information they needed to support each person and keep them safe. The arrangements for supporting residents to make decisions about their daily lives and preferences were satisfactory. Each person was supported to take appropriate risks as part of the Home’s plans to promote as much independence as possible. EVIDENCE: The plans of care for each resident described their needs and preferences and what staff needed to do to care for and support each person. The plans included a range of risk assessments and these detailed the steps to be taken by staff to minimise the risks that had been identified. There were arrangements in place to regularly review and where necessary update each person’s plans of care and assessments. Care plans were being developed to address each person’s longer-term needs. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 11 The questionnaire completed by relatives asked whether they felt the home meets the needs of their relative. All four relatives indicated ‘always’. One relative said that their mother had been worried when her son moved into the home but: “… soon realised it was the best thing she could have done for him”. Another said it was: “A superb set up”. Records indicated the involvement of relevant professionals such as GPs, opticians, chiropodists and dentists. Each resident had key members of staff who oversaw their plans of care. The plans reflected each person’s needs and preferences. Staff supported and encouraged residents to make decisions about their daily lives and routines, such as what time they went to bed and what they wanted to eat or drink. Residents were also involved in choosing activities, outings and holidays, as well as the décor of their bedrooms and the communal rooms. In a questionnaire, residents were asked if they were able to make decisions about what they did each day. Two people indicated ‘always’ and two indicated ‘usually’. But they all indicated they could do what they wanted during the day, during the evening and at weekends. The relative of one person said that the staff gave their relative: “… every opportunity to do the things he enjoys”. Potential risks to each resident, for example when using electrical appliances had been assessed before they were admitted to the home. These assessments were regularly reviewed and updated where necessary. Staff took steps to support each person to be independent while keeping them safe. Some of the residents were not able to leave the Home without the support and supervision of staff. This was recorded in their care plans. Berwick Bridges DS0000000617.V295631.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements were in place for people to take part in appropriate activities in line with their needs and preferences. The arrangements for supporting residents to maintain contact with their friends and family were satisfactory. The relationships between staff and residents were good and personal support was provided in such a way as to promote and protect residents’ privacy and dignity. The meals provide by the Home were satisfactory and gave residents a varied, nutritious diet. EVIDENCE: On weekdays all the residents attended day services that had been identified as meeting their needs. These included attending the local adult training centre and, for two residents, attending a service organised to meet the needs of older people. Each resident had one day a week where they received individual staff support to develop and maintain their self-care and daily living skills. Each person had a timetable of activities. They were supported to take part in a range of activities in a variety of settings. At weekends outings and Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 13 activities were organised, such as trips to Edinburgh or Seahouses. The residents used local amenities such as the bowling club, shops, pubs, theatre and cafés as well as the local healthcare services. Staff said the residents knew the neighbours and got on well with most of them. Staff supported residents to keep in touch with relatives and friends who were important to them. Relatives were consulted about what happens in people’s lives. The residents had opportunities to mix with people who do not have disabilities through the use of what the local community has to offer. The relatives of four people confirmed that staff kept them up to date about issues affecting their relative. There was clear written guidance for staff regarding how they should respect and safeguard the residents’ right to privacy. Staff were observed following this guidance. Residents confirmed that staff respected their privacy. The residents had unrestricted access to all areas of the Home other than the office and each other’s bedrooms. They all helped with household tasks such as clearing up after the evening meal and cleaning the utility room. Throughout the inspection staff were observed talking to, and engaging with the residents. Residents and staff prepared a weekly menu and residents were encouraged to assist with the food shopping and, where appropriate, the preparation of meals. The records of meals provided indicated that they were varied, well balanced and nutritious. Alternatives were available and peoples’ individual preferences were catered for. Healthy eating was encouraged. All of the residents who were asked said that they liked the food at the Home. The staff had all received training in food hygiene. The inspector joined the residents and staff for their evening meal. This was a relaxed, enjoyable, social occasion. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Suitable plans of support were in place and staff had a good understanding of each resident’s support needs. The arrangements for monitoring and meeting the health care needs of residents were satisfactory. This meant that people received the care and support they needed. The arrangements for the administration and recording of medication were satisfactory and protected the residents. EVIDENCE: In their response to a questionnaire all four residents confirmed that staff ‘always treat them well’. One relative said staff were: “… all very caring and considerate” of their brother’s needs. Support plans were in place for each resident describing how their personal and general care needs and preferences would be met. Residents were supported to make choices about their daily lives and routines. Staff also supported and assisted the residents to choose for example, their own clothes, hairstyles and toiletries. The health care needs of the residents had been assessed and were recorded in their plans of care. Their health care needs were monitored and regularly reviewed. Each resident was registered with a local GP and dentist. Residents were supported to access health care services such as dentists, opticians, Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 15 chiropodists and, where appropriate, specialist services such as a dietician. The care manager for two people confirmed that each individual’s health care needs were ‘properly monitored and attended to’. They said there was a: “Comprehensive system of health checks both reactive and preventative” and that “… residents were informed and supported to make choices if possible”. None of the residents were responsible for administering their own medication. No problems were noted in the sample of medication records examined. A lockable storage facility was available for the safe storage of medication. Written consent had been obtained from each resident’s doctor for the administration of non-prescription medication. All of the staff responsible for administering medication to residents had had training in the safe handling and use of medicines. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements were in place for handling complaints and for protecting residents from abuse. There was evidence that residents’ felt they could confide in staff and that their views were listened to. EVIDENCE: The home had a complaints procedure. This was available in a format that could be understood by some of the residents. All four residents confirmed in their response to a questionnaire that they knew how to make a complaint. The relatives of four residents also confirmed this. The home’s complaints record indicated that no complaints had been received by the home since October 1999. Staff had received basic training in the protection of vulnerable adults. Policies and procedures for the protection of vulnerable adults were in place. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The arrangements for keeping the Home clean and tidy were satisfactory. The standard of the accommodation, décor and furniture and fittings was good and provided residents with a clean and comfortable place to live. EVIDENCE: The Home was clean, tidy and homely in appearance. The premises were accessible to all of the residents. The Home is situated close to local amenities and public transport within a small housing estate of similar housing in Tweedmouth. The furniture and fittings were of a good standard. New sofas had recently been purchased. Maintenance and redecoration is carried out at regular intervals. Cleaning materials and other potentially hazardous substances were safely stored. Policies and procedures were in place relating to the Control of Hazardous Substances and Infection Control and other Health and Safety matters. Staff received regular Health and Safety training including Food Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 18 Hygiene. Staff demonstrated an awareness of infection control procedures and an appropriate hand washing facility was available in the kitchen. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. There was a competent team of staff who had access to a range of training opportunities. There were arrangements for ensuring staff received training that covered the specific conditions of residents. This meant that people were being cared for by staff who had had training that covered their specific conditions. The home’s staff recruitment practices were not fully satisfactory in ensuring that only people who have been thoroughly checked are employed at the home. Robust recruitment practices are an important step in ensuring that residents are kept safe. EVIDENCE: The relatives of four residents said that staff at the home ‘had the right skills and experience to look after people properly’. One relative said the staff were: “… all very caring and considerate”. Staff received regular mandatory training such as First Aid, Food Handling, Moving and Handling, Infection Control and Fire Safety. Training programmes were in place and these were linked to staff appraisals and supervision sessions. During the previous 12 months staff had had training that covered: Person Centred Planning, Medication, Dementia, Death, Dying and Bereavement. New staff completed the Learning Disability Award Framework (LDAF) as part of their induction. Over 50 of the care Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 20 staff had a relevant qualification. Two staff were on a course of training leading to a relevant qualification. A sample of staff personnel files was examined. Criminal Record Bureau (CRB) checks had been carried out on all the staff. There was no evidence available that a CRB check had been done for a volunteer who had carried out some of the monthly monitoring visits at the home. Two written references were not on the files of two members of staff. Some of the staffs’ employment histories, as detailed in the application forms they had completed, only specified the years their previous periods of employment had started and ended. This made it difficult to confirm that it was a full employment history and to identify any gaps. All staff appointments were subject to a three-month probationary period. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 42 & 43. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. The manager was suitably qualified and experienced and demonstrated a commitment to provide good quality care and support for the people living at the home. The arrangements for monitoring the quality of the service at Berwick Bridges were not fully satisfactory. They did not ensure that the views of residents, their families, friends and relevant people in the local community are sought about the service provided and how it should be developed. Steps had been taken to keep the residents safe. This meant that residents were, for example protected from the risks of fire. EVIDENCE: The Manager was qualified and experienced. There was evidence that she regularly updated her training and reviewed the care practices within the home. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 22 The home had a Residents Quality Assurance Policy but this policy had not been fully implemented. The manager had prepared a quality assurance questionnaire. It is intended to use this to consult with each resident about the quality of the service they receive. There was evidence that residents took part in more informal bi-monthly meetings where a range of subjects had been discussed. The minutes of these meetings reflected people taking decisions about the quality of their lives. Minutes of the meetings are sent to the Trust’s board of directors. Some monthly monitoring visits to the Home had not been carried out as required under Regulation 26. There had only been nine monitoring visits during the previous twelve months. Staff took part in regular training that covered moving and handling, health and safety, first aid and basic food hygiene. Risk assessments were in place covering safe working practices. Regular ‘in house’ checks of the Home’s fire equipment were being done. Records indicated that staff had regular fire prevention training and took part in regular fire drills. The home’s electrical installations had been checked in December 2004 and arrangements were in place for the Home’s electrical equipment and gas appliances/boiler to be regularly inspected. Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 Score 3 3 X 3 3 X 2 X X 3 X Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 24 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. Standard YA34 Regulation 19 Requirement The Registered Person must ensure that the information and documents specified in Schedule 2 of the Care Homes Regulations 2001 is in place for each person working at the Home and available for inspection. (Previous timescale of 31/01/06 not met.) The Registered Provider must ensure that the visits specified under paragraph 2(b) of Regulation 26 of the Care Homes Regulations 2003, are carried out at least once a month and are unannounced. Ensure that people only carry out these monitoring visits after the completion of a satisfactory Criminal Records Bureau check that includes both POVA and POCA list checks. The Registered Person must establish and maintain a system for: a. reviewing at appropriate intervals; and b. improving, the quality of care provided at the Home. DS0000000617.V295631.R01.S.doc Timescale for action 30/04/07 2. YA39 YA34 26 & 19 30/04/07 3. YA39 24 30/06/07 Berwick Bridges Version 5.2 Page 25 The registered person shall supply to the Commission a report in respect of any review of the quality of care provided at the Home and make a copy available to service users. The system for reviewing the quality of care provided at the Home must provide for consultation with service users and their representatives. 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 YA34 Good Practice Recommendations In order to more effectively identify gaps in employment histories the home’s job application form should be amended to state that applicants must provide the month as well as the year in which their periods of employment commenced and ended. To help ensure that the required checks are carried out on new staff before they commence employment it is recommended that a recruitment and vetting checklist is prepared and used as part of the recruitment and selection process. 2. YA34 Berwick Bridges DS0000000617.V295631.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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