Inspection on 05/12/05 for The Berkeley

This inspection was carried out on 5th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Berkeley 10/07/07

The Berkeley 18/07/06

The Berkeley 24/06/05

The Berkeley 25/02/05

The Berkeley 01/06/04

The Berkeley 09/06/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Berkeley 1 & 2 Elysium Terrace Kingsthorpe Road Northampton NN2 6EN Lead Inspector Mrs Moira Mosley Unannounced Inspection 5th December 2005 10:00 The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 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 The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 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. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Berkeley Address 1 & 2 Elysium Terrace Kingsthorpe Road Northampton NN2 6EN 01604 722033 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) Mentaur Limited Vacant Care Home 14 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (2) of places The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To include up to 2 people over the age of 65 years It is a condition of this registration that the home is authorised to care for the two current named Service Users who have Learning Difficulties and additional Mental Health needs, and one named Service user who has Sensory Impairment in addition to her Learning Difficulties. 24th June 2005 Date of last inspection Brief Description of the Service: The Berkeley, is situated in a residential area in Northampton within approximately 1.5 kilometres of the town centre and local facilities including a town park, and is on a regular bus route. The Berkeley is one of three homes in the locality owned by Mentaur. There is a Day centre locally, run by the organization, which service users have a choice of attending. The house is a large town house of three storeys and a basement, service users have single or shared rooms, on three of the four floors. The ground floor is made up of communal rooms including a lounge, dining room and the staff office. The home has an accessible rear garden for the use of the service users. Access is via steps to the front entrance however level access is available to the rear of the property. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a statutory unannounced inspection; 2 hours were spent gathering information and planning for the inspection and 3 hours were spent in the home. The care of two service users was reviewed to include their care plans, medication and other records. Due to their learning disability some were unable to comment on their care however a period of observation and discussion with two of the service users was undertaken along with discussions with two staff members to ascertain how care is provided. There have been 2 additional inspections on the 2nd September and the 28th October 2005 to monitor compliance with the requirements previously made and to investigate a complaint received at the CSCI. All requirements previously made have been met with the exception of the care plans that are discussed further within National Minimum Standard (NMS) 6. What the service does well: What has improved since the last inspection? Most of the requirements made at the statutory inspection in June 2005 and additional inspections have been met. This includes making the statement of purpose and service user guide available in the home, documenting restrictions made, fitting appropriate door locks to bedrooms and ensuring pest control practices are in place. In addition there have been good links made with the multi disciplinary team to ensure the physical health needs of a service user have been met. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 7 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 The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 8 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): 1 and 2 There is an effective system in place to ensure that resident needs are fully assessed and information available prior to an admission. EVIDENCE: The statement of purpose was available in the home and the service users guides were in all bedrooms when the requirement was reviewed on the 2/9/05. There have been no new admissions to the home for some time although a company assessment process is available to provide a comprenhensive assessment when required. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 9 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): 6 Care plans do not clearly identify the needs of the service users and put them at risk of not receiving appropriate care. EVIDENCE: Care plans and risk assessments for restrictions imposed have been put in place, this was evident within the service user care records and staff were aware of the plans. A requirement was made on the inspection of the 2/9/05 for care plans to clearly identify the care required for the service users, the timescale was renegotiated with the CSCI and is currently due for completion by the 10/12/05. During discussions with staff and a review of service user files it was evident this is unlikely to be completed with no service users records currently up to date. The new care plans in place for one service user are completed to a high standard but continue to be in the file along with all the old plans making it difficult for staff to be able to clearly identify the current expected practice. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 10 Many of the service users still have the old plans, which have not been reviewed or updated for several months. Staff spoken to do not use the care plans on a regular basis to direct the care being provided and there is a reliance on verbal communication of information between the team. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 11 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): 17 Meals and mealtimes are generally well managed to meet service user nutritional requirements. EVIDENCE: Menus are available and the service users are involved at their weekly meeting in the planning of the menus to account for their likes and dislikes. Alternatives are available and recorded to met individual needs. One service users care plan for nutrition was reviewed in April 2005 and stated a list of likes and dislikes would be compiled, this has not been done and on discussion with staff it was evident they use a variety of interventions with this service user and knew a lot about her dietary needs, however there was no documentation to ensure a consistent approach by the team. Service users weights are regularly monitored and there was evidence of input from the GP where issues of concern were raised. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 12 Service users spoken to said they liked the food in the home and could help with preparing drinks and snacks. The kitchen is further discussed within NMS 43. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 13 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): 20. The medication system is unsafe and does not ensure that service users are receiving their medication as prescribed. EVIDENCE: The medication was cross-referenced to the Medication Administration Records for the two service users whose care was tracked. The total amount of medication in the home was not clearly identified and this prevents an audit to ensure medication is being administered as prescribed. The medication procedures available on the home were dated 1996 and there was no procedure for the disposal of medication when it was refused. Staff have been disposing of medication in the toilet or sink which contravenes medication handling regulations. There was a bottle of procyclidine labelled ‘do not use’ with no records to demonstrate what is intended to happen to this. Another service user had medication dispensed from days later in the week from the monitored dosage system, staff were unsure of why this was and the acting manager agreed to investigate further. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 14 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): 22 and 23. The complaints procedure needs to be available for staff; visitors and service users to ensure all complaints are dealt with appropriately. In addition the management of service user monies must include regular checks to ensure any discrepancies are quickly identified. EVIDENCE: The complaints procedure in the policy and procedure files was out of date, having not been reviewed since 2000.This procedure did not include the timescales, contact details or any reference to the CSCI. The complaints file was reviewed and there have been no new complaints. The CSCI investigated a complaint received in September 2005; this was in regard to care of the service users and was mostly not upheld. The exception was in regard to weight loss and requirements made at this time have since been met. Staff spoken to were unsure of how they would deal with a complaint or where they could get the information from but would refer to the homes manager for advice. Service user monies retained in the home are appropriately stored within a safe. The balances cross-referenced to the records maintained. There was no evidence of regular audits by the registered person and all entries had only one signature with no countersignature to evidence verification of balances. The policy for the management of service user money had not been reviewed since June 2003 and the outlined procedures were not being followed. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: These standards were not assessed on this inspection. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: These standards were not assessed on this inspection. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 17 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): 39, 40 and 42. The lack of up to date policies and procedures along with the serious issue of wedging open fire doors and poor food hygiene procedures is putting the service users health and safety at risk. EVIDENCE: There is a quality assurance system that includes questionnaires sent to staff, service users and their families, however these are issued from Head Office and feedback of the outcomes has not been provided to the home. They are unaware of any positive comments made or of any action plans to address the issues raised. The registered provider conducts the monthly visit to the home to audit systems and the service users have regular meetings within the home to discuss any issues that arise. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 18 The homes policy and procedure files were reviewed and although most of the required policies were there and staff have been signing to say they have seen them, all were out of date with most not being reviewed since 2003. At the inspection in June 2005 a requirement was made in regard to the wedging open of fire doors. The action plan from the company stated that automatic closures were going to be fitted and during the monitoring visits the doors were not wedged. On this inspection, 6 fire doors in the communal areas were wedged open with door wedges and an immediate requirement was made for compliance with fire regulations. The kitchen was viewed and both fridges had unwrapped and unlabelled foodstuffs in them. The temperature recordings have been completed three times per day, showing high readings for several weeks. There were no guidelines of expected fridge temperatures, or reporting procedures for unsafe temperatures. In addition the times for taking the temperatures appear to be at high use times when they would not be accurate recordings. The two freezers in the basement area contained open bags of vegetables, one of which had spilled out. There were decaying foodstuffs both in the seals of and on the floors around the freezers. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Berkeley Score X X 1 X Standard No 37 38 39 40 41 42 43 Score X X 2 2 X 1 X DS0000012706.V270868.R01.S.doc Version 5.0 Page 20 NO 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 YA42 Regulation 23(4) Requirement IMMEDIATE REQUIREMENT: All fire doors within the home must not be wedged open. Records must be maintained to evidence the care required for the service users. An action plan for compliance must be submitted to the CSCI demonstrating timely intervention to meet this requirement. A clear audit trail for all medication in the home must be available. The medication policy must be updated and include disposal procedures. The homes policies and procedures must be reviewed, updated and signed by the registered person. There must be a procedure in place for the management of fridge and freezer temperature management, cleaning and storage of items. Timescale for action 05/12/05 2. YA6 17(3) 10/12/05 3 4 5 YA20 YA20 YA40 13(2) 13(2) 17(1)(a) 30/01/06 30/01/06 30/01/06 5 YA42 12(1)(a) 30/01/06 The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 21 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 2 Refer to Standard YA17 YA22 YA23 YA39 Good Practice Recommendations Service user nutritional needs, likes and dislikes should be documented for consistency in meeting needs. The up to date complaints procedure should be available for staff, service users and visitors to the home. Service user monies should be regularly audited with 2 signatures to ensure balances are correct. The results and development plan to address any issues identified from the service user, staff and family questionnaires should be available to the home and the service users. The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 The Berkeley DS0000012706.V270868.R01.S.doc Version 5.0 Page 23 - 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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