Inspection on 04/07/06 for Berwood Court Care Home

This inspection was carried out on 4th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Berwood Court Care Home 06/06/07

Berwood Court Care Home 04/10/05

Berwood Court Care Home 16/11/04

Berwood Court Care Home 20/05/04

Berwood Court Care Home 11/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Berwood Court Care Home Cadbury Drive Castle Vale Birmingham West Midlands B35 7EM Lead Inspector Kath Strong Unannounced Inspection 4th July 2006 09:35 X10015.doc Version 1.40 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 Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berwood Court Care Home Address Cadbury Drive Castle Vale Birmingham West Midlands B35 7EM 0121 749 7887 0121 749 7997 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) Dukeries Healthcare Lisa Geddes Care Home 39 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (39) of places Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home can accommodate thirty nine older people who are in need of personal care or nursing care for reasons of old age or dementia. Minimum number of nursing staff and care staff appropriate to meet the needs of the service users will be provided as agreed with the Commission. Date of last inspection 4th October 2005 Brief Description of the Service: Berwood Court is a 39 bedded purpose built nursing and residential home, which accommodates people of 65 years of age or above who may suffer from dementia. The premises are situated in a residential area of Castle Vale in Birmingham. The care home is located on the first floor of the building and is split into two units, residential and nursing care. All bedrooms are for single occupancy with an en suite facility consisting of toilet and wash hand basin. There are communal lounge and dining rooms available for residents within each unit. Assisted bathing facilities are provided in convenient locations within easy reach of resident’s bedrooms. There is ample off road parking provided. A rehabilitation unit, managed by the Primary Care Trust is located on the ground floor, which is not inspected by The Commission for Social Care Inspection. A shaft lift provides assisted access to both floors. The majority of residents suffer from dementia, which makes it difficult to clearly ascertain their views about the standard of service. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct the fieldwork inspection. The inspection lasted over a period of a long day. The registered manager and administrator provided assistance throughout. Five residents were spoken with individually as well as two relatives. Staff practices were observed and two staff were interviewed. Relevant documentation was examined including five care plans. One resident was case tracked in order to ensure that all identified needs were being met. Medication and health and safety arrangements were checked. Staff files, training and formal supervisions were reviewed. A tour of all communal areas and some bedrooms was conducted. At the conclusion written and verbal feedback was provided to the registered manager. What the service does well: What has improved since the last inspection? The shift system has been reviewed resulting in some staff commencing the morning shift early to accommodate those residents who wish to rise early. A further improvement has been the increase by one care staff during daytime hours. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 6 All staff files have been updated and are presented in a logical format for ease of access. Residents and staff meetings are held regularly. The agenda items suggest that residents are able to influence the day to day running of the home. An activities co-ordinator has been appointed and was due to commence employment the following week. It is anticipated that the standard of activities provided will improve. A fire safety door release has been installed for the resident who prefers to keep her bedroom door open to ensure safe emergency measures are in place . New care plans have been introduced, which was noted to offer comprehensive scope for assessments and care needs, the format of them has also improved. The home has made good progress. Many of the requirements generated from the last inspection have been addressed. 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. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Prospective residents, their families and external professionals are supplied with sufficient documentation to make an informed decision about the home. Although pre-admission assessments are satisfactory some staff have not been trained for provision of care within the category of registration in respect of mental health. The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide were noted to contain all of the required information about the home. The registered manager advised that the two most recent admissions have been supplied with a copy of the service user guide and further copies are available in communal areas. The home is advised to produce the document in different formats to ensure the reader is fully informed. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 9 Prior to pre-admission assessment being undertaken an enquiry form is generated and up dated as required. The assessments carried out by the registered manager or a trained nurse, are satisfactory and upon admission are used as a tool to develop the care plan. Where necessary, reports from external professionals are acquired and used as part of the pre-admission assessment to ensure that residents are confident that their needs will be met upon admission. Prospective residents are encouraged to view the premises, talk to other residents and staff and are invited to sample the food. Further visits may be made before a decision is made. Following admission a trial period of one month is allocated with subsequent review before a placement is confirmed. Due to lack of training in dementia care of some staff the home is not able to demonstrate that all staff can meet all of the identified needs of residents. The home does not provide intermediate care. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The new and improved care planning system requires further development to ensure that residents needs will be met. Health care needs regarding weight loss were not being met thus putting residents at risk. The home is unable to evidence that prescribed creams and food supplements are being administered to residents putting residents at risk. With the exception of meal times residents dignity and privacy are respected. The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The new care planning system in place provides a much improved basis for the documentation of assessments and needs. The files include activities of daily living, strengths, life history, weaknesses, and sexuality, hobbies and pastime preferences. This is considered to be good practice, which will assist staff in determining appropriate health and activities requirements. The files are presented in a logical format and provide the scope for excellent care planning. Some omissions were found in the five files reviewed: Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 11 • • • • • One file recorded weight loss over a two month period but no weights were recorded from 18/01/06 until 10/05/06. Further recording indicates a trend of slow but steady eight loss Two files indicated a steady weight loss but did not provide evidence of action taken to address this. An Immediate Requirement Notice was left at the home Short term conditions such as chest and urinary tract infections have not had care plans compiled. A file indicating a serious urinary infection did not include care plan or instructions for staff to carry out monitoring Although the home has an overall written procedure for dealing with difficult to manage behaviour, the individual files did not provide sufficient details. They should include explanation of likely triggers and resultant behavioural trend. The instructions advising staff on how to respond were satisfactory Notes regarding the most recent admission (10 days earlier) advise of a history of falls, confusion and poor eyesight, however there was no evidence of assessment or care planning having been completed by staff. Lack of an appropriate care plan results in no staff guidance and safe systems of working to meet the needs. An Immediate Requirement Notice was left at the home. There was good evidence of the involvement and a large range of external professionals and resident’s care is supported by their attendance at hospital appointments. The home has an adequate supply of specialist equipment to meet needs and for methods of safe transfers of residents. A resident who is unable to speak informed me through use of body language that she is happy with the standards of care. There was no evidence of a prompt chart in the bedroom but observations indicated that staff were well able to understand when requests were made. She advised that she enjoyed painting; there were a great number of paintings on display within the bedroom. She expressed her preference to remain in her bedroom during daytime hours. The bedroom was arranged to ensure that all immediate needs such as call bell, cold drinks and personal items were at hand. A recently admitted resident said, “I like what I’ve seen so far, staff are very good and my sister can visit anytime”. Feedback from two relatives included, “Very happy with the care staff, well looked after, concerns are sorted out, peace of mind, staff are brilliant, lack of attention when short staffed”. The arrangements for medications were reviewed for the full process. There was good evidence of auditing and action taken for discrepancies found on receipt of new medications. Trained staff advised of the practice of handing prescribed creams and food supplements to care staff to administer, following which the MAR (medication administration record) charts are then ticked by the trained nurse. Trained staff were unable to provide the inspector with Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 12 proof that carers had successfully followed out the instructions/tasks and MAR charts must not contain ticks. Staff were observed being helpful and courteous towards residents and visitors. One carer was seen displaying sympathy when a visiting relative discussed a personal problem. Lunch was observed being served and on two separate occasions care staff failed to provide appropriate assistance. The meal had been served appropriately but staff were observed mixing the various foods together within sight of the resident. Such practices inhibit the resident’s ability to enjoy varied tastes and textures resulting in lack of respect of individual’s dignity. The registered manager was advised to promptly address the problem and to monitor carer’s practices. The home has a system installed that requests staff to activate it upon entering a resident’s bedroom. This is used as a monitoring/quality assurance tool in respect of frequency of checks carried out. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 14 and 15 Activities available are not adequate to meet residents recreational needs. Residents have some influence of the day to day operations of the home. A varied and nutritious diet is provided and choices are offered. The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager advised that since the last inspection difficulties had been encountered in employment of an activities organiser, however someone was due to commence the following week. Information provided was that there is no programme available and there are no records maintained of those residents who participate with the ad hoc programme. A voluntary worker visits the home once a month accompanied by a church cleric. The home holds an annual fete within the courtyard as a means of fundraising to pay for external entertainers. Other means of fund raising include barbeques, raffles and bring and buy events. A relative said, “Activities are not adequate”. The minutes of the residents meeting held January 2006 included topics such as communications, comments, staffing, the new care plans, audit questionnaires, activities, fund raising, the new chef and questions and answers. A date has been arranged for the next meeting to take place soon. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 14 The manager advised that relatives are invited to attend the quarterly meetings. Due to the mental health needs of the majority it was not always possible for the inspector to hold meaningful conversations with residents. Observation indicated that staff have developed a means of communication with these residents. The door of a resident who has difficulty in identifying her bedroom has been clearly and brightly labelled. Chairs have been strategically placed along corridors where residents can take a break when walking from room to room. This is viewed as being good practice in maintaining residents independence. Risk assessments have been completed for any resident who is unable to hold their own bedroom door key. Residents are encouraged to request that their room is kept locked when unoccupied. A care plan instructs staff to listen to a resident even if the conversation is not rational. Written policies regarding access to health care records includes staff guidance in respect of many religions for a varied number of ethnicities. Residents and relatives informed of the homes open policy regarding visitors who reported that they are always made to feel welcome. The four-week rolling menu is comprehensive in offering good choices for all meals including a cooked breakfast. Night staff serve tea and toast at 9pm and the fresh fruit supplied throughout the day is replenished. The two dining areas are nicely set up with damask tables cloths on tables. Lunch, which is the main meal of the day and the evening meal, were observed being served. Individual requests were being catered for. Residents may choose to have meals in their bedrooms. The standard and variety of the meals appeared to be good. The home caters for special diets and where necessary cultural needs. Water, soft drinks and tea were served throughout the day. Due to the high temperature on the day of the inspection staff were observed encouraging and supporting residents in taking frequent drinks. Residents provided the following comments, “Food up to now is OK, food is very nice”. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The complaints procedure ensures that residents are listened to and action taken as required when concerns are raised. The lack of training of some staff in adult protection puts residents at risk. The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The complaints procedure supplied during the inspection did not include a timescale for resolution. A procedure forwarded to CSCI subsequently did include all information. The home is advised to ensure uniformity in by working from one procedure only and is advised to produce a document that is user friendly for the current client group. The complaints file was examined and pervious complaints had been investigated and dealt with appropriately. The home and CSCI has not received any formal complaints since the last inspection carried out October 2005. As part of quality assurance the registered manager carries out regular audits of complaints. The written policies regarding prevention of abuse and whistle blowing are satisfactory. The home also uses ‘No Secrets’ and Birmingham County Council guidelines as additional tools. Some staff have not received training in this aspect of care. This was demonstrated during discussions with a member of staff. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 Residents are provided with homely, comfortable, well maintained and safe accommodation. There are insufficient assisted bathing facilities to meet the needs of the current client group. Hygiene levels and infection control practices are robust. The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises, furniture, fixtures and fittings are of a good standard throughout. Corridors are wide providing good access for wheelchair users. There are two lounges, which appear to be used individually for nursing and residential residents. There is also a pleasant small room that is utilised as a quiet room. Each main lounge has a separate dining area. These rooms were noted to be comfortable and inviting. The large unused room situated on the ground floor lends itself for provision of activities, meetings and socialising events. The central garden located on the ground floor, is shared with patients Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 17 from the rehabilitation unit. There is also a garden around the perimeter of the building but this does not include paving, planted areas or shaded areas with seating. The development of this area would provide residents with a pleasant alternative area. Advice has been given at the previous inspection that this would be developed to create a dedicated for Berwood Court residents to frequent. The maintenance operative checks and records the temperatures of communal rooms to ensure an acceptable ambient temperature is maintained for resident’s comfort and well being. All bedrooms have en-suite facilities consisting of toilet and wash hand basin. Communal toilets are strategically located. There is one assisted shower room and a well equipped assisted bathroom. The other two bathrooms include a seated hoist, the registered manager advised that these two bathrooms are not practical and therefore not used. It was noted during the inspection that many of the nursing residents are highly dependant; therefore two well equipped bathrooms are insufficient to meet all health care needs. Bedrooms are all single rooms have en-suites, a lockable facility within the rooms and suited door locks. Advice was given that residents are offered a key and some request that staff lock unoccupied rooms during daytime hours. The preferred arrangements are clearly documented for each resident. The rooms visited were very personalised and some included many items of resident’s own furniture. The kitchen and laundry rooms were found to be tidy, well organised and efficiently run. Both provide a service for the rehabilitation unit. The premises throughout were fresh and hygienic. The required water testing has been carried out including regular testing of all hot water outlets accessible to residents. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels are adequate to care for the numbers and dependency levels of the current client group. Recruitment practices are robust and therefore protect residents from harm. The amount and calibre of staff training is inadequate to enable all staff to carry out their roles or meet the individual or collective needs of residents. The quality outcome for this area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recently re-organised shift patterns has resulted in an extra carer being on duty during daytime hours and the commencement times for the morning shift are staggered to cater for those residents who wish to rise early. The registered manager said she is building up a team of bank staff and that agency staff are utilised infrequently to ensure continuity of care. A full team of ancillary staff are employed for all other aspects of the service including a maintenance operative. The five staff files examined revealed that all necessary checks are carried out before employment is commenced, which safeguards residents. The home has a copy of the Skills for Care programme and this will be used as the induction future tool for all care staff. Staff are encouraged to complete NVQ level 2 training and files revealed that seven staff have also completed Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 19 level 3. There were notices on display advertising training, which would provide staff with the knowledge and skills to meet individual/specialist needs of residents. As discussed previously some staff have not received training in dementia care and adult protection. The training matrix indicates that there are some gaps in mandatory training, which need to be completed this year. A concern expressed to the registered manager was the length and standard of the courses recently supplied for staff in respect of Moving and Handling and Health and Safety. The syllabus of each course is inadequate; this was confirmed by testing staff knowledge. A further concern was the inappropriate response given by a member of staff to a question involving the health and well being of a resident. Training supplied to the home must be comprehensive. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 The registered manager has good vision for the development of the home and staff have clear lines of accountability. The Health and Safety arrangements ensure that residents are protected from harm. The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has the skills and experience to ensure efficient day to day operations and development of the home. A unit manager supports her. Good relationships were observed between senior, care and ancillary staff, residents and relatives. The staff interviewed provided positive information regarding the manager and that they felt confident about raising issues of concern with her. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 21 The inspector was supplied with a copy of the homes quarterly quality assurance report, which is shared with residents and staff. An extensive range of audits are carried out including the premises, resident’s questionnaires, documentation and staff practices. The arrangements for the safe keeping and financial transactions of personal monies held on their behalf are satisfactory. A relative spoken with reported that insufficient notice is given by the home for the topping up of his Mothers personal money. The programme of regular formal staff supervisory meetings has not been fully established. This indicates failure to monitor staff performance and test their knowledge base. The home complies with all aspects of health and safety requirements. This includes weekly testing and recording of fire alarm system as well monthly emergency lighting checks. Accidents are appropriately recorded and investigated as necessary ensuring that monitoring and appropriate action is taken as required. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 23 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. 2. Standard OP4 OP7 Regulation 18(1)c i 15 Requirement All staff must receive training in dementia care in order to comply with the homes registration. Care plans must be further developed to include: • Short term conditions • Difficult to manage behaviour • Gaps must be addressed. Care plans of newly admitted residents must be completed within an acceptable time frame. All residents must be weighed monthly. Identified weight loss must be investigated and reported to the appropriate authorities. Two members of trained staff must sign all written instructions of prescribed medications entered on MAR charts. Staff must not record ticks on MAR charts. The home must introduce a means of verifying that prescribed creams and food supplements have been Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 24 Timescale for action 31/10/06 30/09/06 3. 4. OP7 OP8 15 12(1) 06/07/06 11/07/06 5. OP9 13(2) 15/08/06 6. OP12 16(2)n administered correctly. Due to the high proportion of residents with dementia care needs, the Home Manager must review the activities on offer having regard to the needs of these residents. N.B. This is outstanding from the last three inspections. The activities co-ordinator must develop an activities programme suitable to meet the needs of all residents living at the Home after consultation with residents and/or their representatives. N.B. This is outstanding from the last inspection. 30/09/06 7. 8. 9. OP13 OP18 OP30 16(2)n 13(6) 18(1) The home must maintain records of those residents who have participated with activities. Residents must be offered 30/09/06 outings and access to the local community. All staff must receive training in 31/10/06 adult abuse and difficult to manager behaviour. All staff must receive mandatory 31/10/06 and respective refresher training. N.B. This was made at the last inspection in the form of an Immediate Requirement. The syllabus for training regarding Moving and Handling and Health and Safety must be comprehensive and sufficient to provide staff with the knowledge and skills. The registered manager must ensure that all staff possess the knowledge and skills to ensure the health and well being of residents are met. The system for formal staff supervision and appraisal must be fully implemented and DS0000024824.V301789.R01.S.doc 10. OP30 18(1) 31/08/06 12. OP36 18(2) 15/10/06 Berwood Court Care Home Version 5.2 Page 25 ongoing. 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. 2. 3. Refer to Standard OP29 OP35 OP19 Good Practice Recommendations It is recommended that CRB checks are repeated every three years for existing staff. It is recommended that relatives are provided with realistic timescales for the top up resident’s personal monies. The Organisation should further consider arrangements in respect of the external grounds/facilities for residents living at the Home. Outstanding from last inspection. Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Berwood Court Care Home DS0000024824.V301789.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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