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

This inspection was carried out on 6th June 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 but made no statutory requirements on the home.

Other inspections for this house

Berwood Court Care Home 04/07/06

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 Key Unannounced Inspection 6th June 2007 09:25 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.V336817.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.V336817.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 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.V336817.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. 4th July 2006 Date of last inspection 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 a good supply of specialist equipment to assist people who have restricted mobility. A call system is in all rooms. 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 at times to clearly ascertain their views about the standard of service. The fees charged by the home are £454.00 for residential and £562 for nursing care. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was carried out over a period of one day. Assistance was provided throughout by the manager. Information was gathered from speaking with people who live at the home, relatives and staff including two staff interviews. Care, health and safety and the arrangements for medications were reviewed. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Further information was obtained from the Annual Quality Assurance Assessment carried out by the home and sent to CSCI prior to the fieldwork visit. Comments were also received from the questionnaires completed by people who live at the home. At the conclusion verbal feedback was given to the manager. No Immediate Requirements were made. What the service does well: What has improved since the last inspection? Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 6 A review of the housekeeping duties has been carried out resulting in improved hygiene standards for the benefit of the people who live at the home. Staff morale has improved resulting in low sickness rates and lack of agency staff. This ensures that there is consistency in delivery of care. This has also resulted in staff respecting each other and effective team working. A new trainer has been employed by the organisation and the standards of the training provided to staff have improved. A health and safety assessment of the home has been carried out and the findings used as part for the proposed staff training. This will ensure that staff are competent to carry out their roles effectively and safely. Landscaping of the second garden has commenced to improve the outside facilities for people who live at the home. The nursing lounge has been redecorated. Two bedrooms per month are decorated to provide a pleasing environment for people to live in. Senior care staff take a lead role in the management of the care and services provided to residential clients. What they could do better: The home must ensure that the Annual Quality Assurance Assessment is returned to CSCI within 28 days as this is a legal requirement. The responsible individual must supply the inspector with specific details when a manager is appointed. The practice of disarming the door of the nurses office must cease and the room kept locked if COSHH products and confidential information is accessible. The arrangements for the signing in and out in the visitors book needs to be reviewed to ensure that all visitors are captured going into and exiting the home. The process for the administration of prescribed creams and auditing of new supplies from the pharmacist needs to be improved. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 7 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. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 8 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.V336817.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents, their families and relevant others are supplied with sufficient written details about the home for them to make an informed decision about living at the home. The arrangements made and pre-admission assessments carried out are comprehensive and enables the home to demonstrate that it can meet the persons needs at the time of admission. EVIDENCE: The statement of purpose and service user guide provides all the relevant information to assist people in making a decision about the services provided by the home. A copy of the service user guide is given to people who go to the home for a look around and to meet other people residing there. The document includes details about how the fee rate is calculated and the various elements included within it. People who decide to move into the home are given a six week trial period; a review by both parties is carried out before a Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 10 placement is confirmed. Both documents will require amendments regarding the manager’s details. A contract of terms and conditions of residency is supplied to all people who reside at the home. The contract provides adequate information about the rights that people who live at the home can expect. The annual quality assurance assessment completed by the home and forwarded to CSCI provides information about how people are assisted in making a decision about living at the home. The manager completes an enquiry form and sends an information pack the enquirer and advises of the homes website address. When people visit the home they are encouraged to read the statement of purpose and inspection reports. A person who already lives at the home said she made a number of visits before making up her mind. The manager carries out a pre-admission assessment, answers any questions raised and provides information about the services and care planning. The home is able to supply documents in various formats to promote peoples understanding of the services available to them. Two copies of pre-admission assessments were seen during the inspection and they appeared to include all relevant information. This enables the home to determine that it could meet all of the individuals needs at the time of admission. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples needs are being identified and good arrangements are put in place to promote their health and wellbeing. Staff practices in respect of safe administration of medications need to be improved to ensure that medications are administered safely. EVIDENCE: Each person has a written care plan. This identifies the assessments carried out and details the care that staff should provide to promote the individuals health and wellbeing. Four care plans were reviewed consisting of the two latest admissions to correspond with the pre-admission assessments and two who have various illnesses. The home has continued with the new care planning system that was introduced last year. This is an improved method because it covers all aspects of care needs and contains people’s personal preferences. Personal details include activities of daily living such as the time of rising and retiring to bed, background and life history. Other assessments Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 12 are carried out to determine peoples weight, nutritional status and if they are prone to pressure ulcers from lack of mobility. This suggests that the care provided is appropriate and that personal preferences are actioned. Care plans are reviewed monthly and regular formal reviews are carried out with the respective person or their family being invited to participate and confirm the care that needs to be delivered. The individuals’ ability to hold their own bedroom door key is assessed to promote their personal privacy needs. Some shortfalls were found that require attention: • A care plan stated that the person likes to retire at 7pm but the life history stated 10pm • Where people or families record daily living assessments these should be signed and dated by the author or the member of staff on receipt of them. Comments were made about the standards of care; “I am quite satisfied here, it’s a lovely place to stay, staff will get the doctor out when needed”. A person who has been living at the home for a considerable period of time communicates by making a noise, pointing and body language. Observations revealed that staff have a good understanding of her needs and are able to communicate well with her. There was good evidence of a proactive approach to using the services of external professionals to assist staff in providing the most appropriate type of care and to monitor the persons wellbeing. The arrangements for the ordering receipt, storage, administration, recording and disposal of medications was assessed. The medications of the persons whose care plans were seen were checked. In some instances the medications received from the pharmacist had not been signed to confirm that the correct medications had been dispensed. This needs to be avoided to ensure that the correct medication and amounts are being administered to people. The practice of trained staff entering a tick on MAR (medication administration record) charts must cease. All administrations must be signed. The home needs to develop a safe system regarding the administration of prescribed creams by care staff. Staff were observed using the preferred term of address towards people living at the home. Personal care was delivered in the privacy of peoples own bedrooms or a bathroom to preserve their privacy and dignity. Staff were noted holding conversations with people and their visitors about care needs. Berwood Court Care Home DS0000024824.V336817.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The social activities are not sufficient to enable people who live at the home to enjoy a quality lifestyle. Residents and families are encouraged to influence the day to day running of the home and that peoples independence and individuality are promoted. People are able to exercise choices and are offered a nutritious and balanced diet but meals are not served at an appropriate temperature to promote peoples enjoyment of them. EVIDENCE: The home currently employs one part time activities organiser who works for two days each week. The manager acknowledged that this is inadequate and is advertising for another person. Four of the questionnaires returned to CSCI by people who live at the home stated that there are not enough activities. There is a programme, which is reviewed weekly to advise people of the recreations for two days each week. The programme indicated that varied and interesting activities are provided. In the absence of a second activities organiser care staff have taken on the role of providing other recreations each afternoon. During the visit two care staff held a bingo session, this was observed to be well attended and conversations were friendly and light hearted Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 14 to enhance peoples enjoyment. Life histories, personal preferences and aspirations have been recorded and those who have participated in activities are being recorded. This assists staff in monitoring peoples preferences and where changes in the programme need to be considered. Each evening an alcoholic beverage is offered to all people at the home to enhance the evening socialising that takes place between residents and visitors. Special occasions and birthdays are celebrated. A birthday celebration was in progress during the visit. A group of people were in the garden enjoying champagne and the birthday cake that the cook had baked. A number of people were enjoying a visit to the garden during the day. Some relatives provide valuable assistance with the activities to enhance peoples enjoyment and lifestyles. The home is carrying out fund raising events to assist people in having outings. Visitors take their relative out to various locations such as walks, shopping or a pub for a meal. The home has also requested funding for some people to attend day centres but to date had not been successful. This restricts people from enjoying access into the community. The manager advised of the poor attendance at meetings she had arranged for residents and their families to discuss the day to day operations of the home and social events. The manager advised that she is planning to hols evening and/or a weekend meeting to be flexible towards visitors personal commitments. She also makes herself available for one to one meetings that people may prefer. The home has a four week rotating menu, the main meal of the day is served at lunchtime. Two choices are given for the main course and yoghurts and ice cream can be requested if people do not wish to have the desert. The evening meal consists of soup, a light meal or various cold foods. The cook provides each unit with food items for staff to make light snacks and ensures that fresh fruit baskets is available at all times. These arrangements suggest that people are offered a varied, balanced and nutritious diet. Lunch was observed being served in each of the two units. Meals are served from a hot trolley in the nursing unit before being transferred to the residential unit. Meals were nicely served and staff provided discreet assistance. Some visitors were also assisting their relatives to have their meal. In the nursing unit the hot desert was served into bowls, which were placed on the kitchenette unit and the hot trolley was transferred to the residential unit. Leaving deserts on an unheated surface is not acceptable practice. Staff were observed completing the assistance in the nursing lounge before going into the residential lounge to serve lunch. This indicates that there was no reason to leave deserts on an unheated surface to cool. Staff need to ensure that meals are served at an appropriate temperature to ensure that people are given opportunity to enjoy their meal. During a conversation with a relative she Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 15 said, “Mum has not been eating well but staff will ask me what she would like such as yoghurt at breakfast time. A person living at the home said about food, “Its excellent”. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home and their family are confident that their views will be listened to and complaints dealt with effectively. The arrangements in respect of adult protection are robust; these protect people from risks of harm. EVIDENCE: The home has a copy of the complaints procedure on display to advise people how they should proceed when concerns are found. The home has three books located at convenient areas for people to record grumbles. Senior staff record what action they have taken to address the problem. The home had received one complaint since the last inspection of July 2006. Recordings indicated that appropriate action had been taken for the concern to be investigated. No complaints have been sent to CSCI for investigation. The home uses the Birmingham multi-agency guidelines and the Department of Health’s Protection of Vulnerable Adults guide to educate staff regarding their roles when abuse is suspected. There is also a Whistle Blowing policy on display to encourage people to act appropriately without fear of discrimination. No concerns about abuse have been raised since the last inspection. Two staff spoken with demonstrated that they possess adequate knowledge to take correct action when abuse is suspected. Staff have received training in this aspect of care. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a warm, comfortable and well maintained environment. There are sufficient adapted facilities and equipment to assist people who have restricted mobility. The good levels of hygiene and staff practices prevents people from developing infections. EVIDENCE: The premises, furniture, fixtures and fittings are of a good standard in providing a pleasing environment for people to live in. Corridors are wide and permit good access for wheelchair users. One lounge is occupied by people who require nursing care and the other by those who require personal care. There are no restrictions imposed on people, they can access any communal room. Both lounges include an integral dining area and kitchenette where snacks and refreshments can be made at any time. There is a quiet room that Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 18 people can access, this was being used by very dependent people at the time of the inspection. The large room situated on the ground floor is not being used for its purpose of activities. The central garden is accessed from the ground floor and is shared with Primary Care Trust patients who occupy the ground floor. The ground floor is not registered with CSCI and therefore is not inspected. There appear to be no problems encountered by both people from both units accessing the garden. There is also a perimeter garden, which was currently being landscaped but there were no seating facilities. The home has arrange of assisted bathing facilities including baths and showers to enable people to make choices about the mode of bathing they prefer. All bedrooms have en-suite facilities consisting of toilet and wash hand basin. The ground floor can be accessed by stairs or a shaft lift. The home has six hoists and a variety of equipment to assist people with restricted mobility in making safe and efficient transfers. All rooms have a call system to enable people to summon assistance when they need to. All bedrooms are single occupancy and include a lockable facility for the safe storage of private and financial possessions. Following admission people are assessed regarding their ability to hold their own bedroom door key to ensure that privacy and dignity are being promoted. The manager advised that one person had been assessed as not being able to hold his key, staff lock his bedroom when he is accessing communal rooms. One person said, “I’m satisfied with my room”. Communal rooms and some bedroom doors have had signage installed to assist people who have dementia in recognising those rooms. This is good practice and promotes peoples independence. The home was tidy and hygienic throughout and well ventilated. During hot weather the temperature needs to be monitored and extra drinks offered to people because the home can be excessively hot. Hot water temperatures are regularly checked and recorded to prevent people who like at the home from risks of scalds. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are maintained in sufficient numbers to ensure that peoples needs are met. Recruitment practices are robust and protect people who live at the home from risks of harm. Staff training is provided to ensure that they have the knowledge and skills to carry out their roles effectively. EVIDENCE: The staffing levels were assessed and found to be satisfactory. A trained nurse is allocated to oversee the care of people who need nursing care and senior carers take charge of the residential area during daytime shifts. The home has a full complement of ancillary staff to enable care staff to carry out their designated roles. Comment made by people living at the home were, “Staff are very good, staff are helpful, they care about you, staff are excellent, even the domestics are friendly”. Four staff personnel files were checked to give information about the homes recruitment arrangements. They indicated that all of the required checks are carried out and two satisfactory written references are obtained before a post is offered. This suggests that peoples safety is paramount. As well as the homes own induction staff are expected to complete a programme that includes all the items listed in the Skills for Care programme. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 20 The home is working towards at least 50 of staff successfully completing training in NVQ level 2 and eight staff possess NVQ level 3. All staff have completed training in Fire Safety, First Aid, Infection Control, Moving and Handling and arrangements were in place for them to receive training in Health and Safety. This will ensure that staff are able to provide the standards of care that people who live at the home should expect to receive. Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced and possesses the skills to oversee the day to day management of the home. The quality assurance arrangements ensure that sustained and ongoing improvements are being made for the benefit of those who live at the home. Arrangements in respect of health and safety fail to prevent risks of injuries from occurring. EVIDENCE: The manager has the skills to effectively provide the day to day management of the home and staff. She is supported by a senior nurse and senior carer. Staff spoken with provided positive feedback about the management arrangements and the support provided to them by the manager. During the inspection an ‘open door’ approach was adopted by the manager and she gave Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 22 advice and support to both residents and staff. A member of staff spoken with gave praise about the manager, “She is wonderful, like a breath of fresh air”. The organisation has an extensive quality assurance system in place that covers all aspects of the services provided. This includes questionnaires that are distributed to people living at the home and their relatives. The results are collated and any shortfalls identified are allocated a timescale to put them right. Regulation 26 visits and reports have been completed by the registered individual for most months but not all. The arrangements for the safekeeping and financial transactions of peoples personal monies are good, this prevents financial abuse. Staff meetings are held regularly to ensure they have up to date information about the home and peoples needs. The manager advised that the written policies and procedures were due to be replaced during the following week. Care plans are stored safely to prevent inappropriate access to them and to maintain confidentiality. Accident records are good and there is evidence of monitoring to determine trends so that the home can take action to prevent more occurrences. All relevant checks and servicing of equipment are carried out to ensure that they are fit for purpose. The fire alarm and emergency lighting systems are regularly checked and the findings recorded to protect people from harm in the event of an emergency situation. Fire drills are carried out and staff who have participated are recorded to ensure that all staff are captured during the year. The arrangements for all visitors to sign in and out of the premises are not efficient. The allocated signing in book is not in a suitable location to attract peoples attention and the person who was manning the reception desk did not ask the inspector to sign in. The door to the nurses office was found to be propped open and was unoccupied. On entry a number of base cupboards were unlocked and some contained spray cans. This poses a significant risk to people who live there and wonder about the home. This was compounded by the fire safety closure being detached from the door, which can result in further health and safety risks to people and staff. Berwood Court Care Home DS0000024824.V336817.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 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 2 Berwood Court Care Home DS0000024824.V336817.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Staff must not record ticks on MAR charts. This remains outstanding from 15/08/06. The home must introduce a means of verifying that prescribed creams and food supplements have been administered correctly. Staff must verify by signing the MAR charts that all medications received into the home are audited against the prescription. This is needed to evidence that people are administered the correct prescribed medications to promote their health. 2. OP12 16(2)n 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. . This is outstanding from the last four inspections and must be addressed. DS0000024824.V336817.R01.S.doc Timescale for action 10/07/07 30/08/07 Berwood Court Care Home Version 5.2 Page 25 3. OP15 16(2)i Meals must be served at an appropriate temperature to ensure that people are able to enjoy the food. 15/07/07 4. OP30 18(1) At least 50 of care staff 30/09/07 employed have successfully completed NVQ level 2 to ensure that they possess the knowledge and skills to meet peoples needs. The visitors book must be accessible to and completed by all people who enter the home. This practice ensures that appropriate action will be taken in the event of an emergency situation. All COSHH items must be securely stored to prevent accidental ingestion by people who live at the home. 31/07/07 5. OP38 13(4)a 6. OP38 13(4)a 05/07/07 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 OP29 Good Practice Recommendations It is recommended that CRB checks are repeated every three years for existing staff to ensure that people who live at the home are protected from harm. Berwood Court Care Home DS0000024824.V336817.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: 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 Berwood Court Care Home DS0000024824.V336817.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!