Care Home: Berecroft Home

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What the care home does well The service has a clear and thorough pre-admission process that makes sure that the people coming to live there have been thoroughly assessed and the home has decided that it can offer them a positive experience. The care plans and risk assessments used in the home are detailed and give staff enough information to provide care that is centred on the individual. People loving in the home are happy and comfortable. Care is given to them by a team of competent staff who genuinely care about the people they work alongside. Records examined confirm that staff supervisions are being carried out. Staff spoken with on the day of the inspection visit feel well supported. Staff who are well supervised and receive appropriate support from management perform better and this improves the service for people who live there.Records examined confirm that staff supervisions are being carried out. Staff spoken with on the day of the inspection visit feel well supported. Staff who are well supervised and receive appropriate support from management perform better and this improves the service for people who live there. On the day of the inspector`s visit the atmosphere in the home was relaxed and the inspector was given every assistance from assistance from the acting manager, the administrator and members of staff. Berecroft provides a service that values the individuality of people who live there. Interactions between staff and people in the home are good. Staff are able to provide support for people in a way that meets their needs and wishes. What has improved since the last inspection? People who use this service must be assured of a good service through the management and record keeping of medication entering the home, leaving the home and being disposed of. CARE HOME ADULTS 18-65 Berecroft Home 317 Berecroft Harlow Essex CM18 7SH Lead Inspector Sharon Thomas Unannounced Inspection 1st July 2008 10:00 Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berecroft Home Address 317 Berecroft Harlow Essex CM18 7SH 01279 410859 01279 442309 susan.crowley@essexcc.gov.uk www.essexcc.gov.uk Essex County Council 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) Mrs Susan Anne Crowley Care Home 25 Category(ies) of Learning disability (25), Learning disability over registration, with number 65 years of age (4) of places Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 25 persons) Four persons of either sex, aged 65 years and over, who require care by reason of a learning disability The total number of service users accommodated in the home must not exceed 25 persons 4th June 2007 Date of last inspection Brief Description of the Service: Berecroft care home is owned and managed by Essex County Council. It provides accommodation and care for people with a learning disability over the age of eighteen. The home works with service users to develop their daily living and independence skills. The home is divided into four cottages and one bungalow, which have a total of twenty-five single bedrooms. Service users have the opportunity to attend a day centre or access community based resources. The home is well maintained with pleasant gardens. A local shop, church and public transport are all within easy walking distance of the home. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as food records, staff rotas, care plans and personnel files. An Annual Quality Assurance Assessment with information about the home was completed by the manager and sent to us before the inspection. Throughout the report this document will be referred to as the AQAA. A visit to the home took place on 1st July 2008 and included a tour of the premises, discussions with some of the people living in the home, the two acting managers, and members of staff. Some of the people living there have complex needs and are unable to communicate verbally, although the inspector was able to have some communication based around facial expressions and gestures. Observations of how members of staff interact and communicate with people living there have also been taken into account. The previous manager of the service has recently resigned and the service has ensured that the home is being well run by putting two highly experienced managers in place. What the service does well: The service has a clear and thorough pre-admission process that makes sure that the people coming to live there have been thoroughly assessed and the home has decided that it can offer them a positive experience. The care plans and risk assessments used in the home are detailed and give staff enough information to provide care that is centred on the individual. People loving in the home are happy and comfortable. Care is given to them by a team of competent staff who genuinely care about the people they work alongside. Records examined confirm that staff supervisions are being carried out. Staff spoken with on the day of the inspection visit feel well supported. Staff who are well supervised and receive appropriate support from management perform better and this improves the service for people who live there. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 6 Records examined confirm that staff supervisions are being carried out. Staff spoken with on the day of the inspection visit feel well supported. Staff who are well supervised and receive appropriate support from management perform better and this improves the service for people who live there. On the day of the inspector’s visit the atmosphere in the home was relaxed and the inspector was given every assistance from assistance from the acting manager, the administrator and members of staff. Berecroft provides a service that values the individuality of people who live there. Interactions between staff and people in the home are good. Staff are able to provide support for people in a way that meets their needs and wishes. What has improved since the last inspection? What they could do better: Some staff in the home lack an understanding of links with external safeguarding agencies and how safeguarding procedures work, this could pose a potential risk to vulnerable people and must be addressed by the management team. Staff do not know whom to contact should the allegation be made against a member of the staff team. The training programme used in the home needs to be well maintained and accurately record which staff have had what training. The management team need to make sure that the Quality assurance system is implemented so that there is a formal process of gathering people’s views and acting upon them. The managers AQAA could provide a more detailed account of the service. They should continue to make improvements to the environment, particularly around providing a well-decorated domestic and homely place for people to live in. The service must start the recruitment process for the manager’s post. Berecroft Home DS0000034845.V368177.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. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standard 2 and quality in this outcome area is good. People choosing to live at Berecroft Home receive sufficient information about the home and may be confident their needs will be assessed before admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager confirmed that the service has admitted one new person since the previous inspection. This person’s care plan file was examined and we found that the management of the home had gathered all of the information that it needed before the person came to live there. The acting manager discussed her pre-admission process and it was clear that the management of the home would use a thorough and thoughtful process to ensure that the service could meet the needs of the person thinking of moving in. The acting manager said that the service has a Service User Guide in place that can be provided in different formats such as large print and symbols. The guide gives information that will help people wishing to move into the service make a choice as to whether it is the right place for them. There is also a Statement of Purpose available that can also be produced in different formats. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 10 A discussion with the acting manager confirmed that they use Essex County Council’s assessment process. This is a robust process that involves carrying out a pre-admission assessment, which is comprehensive and covers a wide range of areas of need. The manager says in the AQAA that “We have a programme for admission tailored around each individual and their needs. This will include providing them with the Statement of Purpose and Service User Guide; a transitional/assessment period that includes a phased introduction to the home and others who live here”. The acting manager said that the service would give the individual a twelve week trial placement, during which time the person will be supported by a nominated key worker to help them settle in. After the trial period, there will be a review with the person and any other relevant parties such as relatives. At this review a decision is made as to whether the placement is suitable and the person wishes to stay. A sample of indicvidual records that we looked at all contain a service agreement with details of the terms and conditions of the service. This ensures that everyone is clear about their rights and responsibilities. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standards 6, 7, and 9 and quality in this outcome area is good. People living in Berecroft benefit from having good care plans that recognise and value people’s individuality. They are supported to make decisions about their lives and take part in the running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of people living at the home were examined and we found that they have been updated and reviewed since the home’s last inspection. Staff spoken with during the inspection had an overall understanding and awareness of the needs of the people in their care and were observed to be patient and caring when interacting with them. Staff were chatting and including people while undertaking a variety of tasks around the home. Peoples’ files contain clear information about their health needs and how they are to be met by staff. The delivery of personal care is individual and flexible Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 12 according to changing needs and preferences of people living at the home. Care plans are regularly reviewed with signatures and dates recorded. Evidence of visits by healthcare professionals was found in the care files that we inspected and records kept of medical referrals, actions and outcomes. Records examined confirm there are risk assessments in place, including manual handling assessments. The assessments identify the risk and record what measures are in place to reduce the risk. Therefore staff are provided with information that helps them keep people safe. Risk assessments were seen evidencing that the people living at Berecroft Home were supported to take risks as a part of developing independent lifestyles. The records sampled were clear and concise in respect of identifying the nature of any risk and the guidelines to be followed by staff supporting the individuals to ensure that the risk was minimised. By having good risk assessment sin place staff are better equipped to support people to carry out daily tasks in a safe manner. The administration of medicines was observed to be safe, and we found the records we examined are accurate, also, the safety of people is supported by relevant and appropriate medication policies and procedures. All medicines are appropriately stored in a lockable cabinet. Comments received from two people living in the home and observations carried out during the inspection confirmed that people living at the home are treated with respect and their right to privacy is maintained through the good practices and the awareness of staff to the needs of the people living there. We saw that people are treated with respect. While walking around the home the acting manager knocked on doors before entering individual and communal areas. The complex needs and communication difficulties of people living in the home meant that the majority are unable to answer questions, but we could see from the way people responded to staff that people were relaxed and comfortable with they way they were being supported. The manager says in the AQAA that “Regular service user meetings to ensure we have an opportunity to listen to their collective views; service users participate in purchasing their food and devising their menu’s and have ample opportunity to change and develop this according to their needs and taste”. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standards 12, 13, 15, 16 and 17 and quality in this outcome area is good. People living in Berecroft Home can expect to have opportunities to participate in activities that are appropriate to their needs and to be supported to build and maintain relationships. People can expect to be offered a varied diet that provides them with choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person’s care plan contains an individual activity plan. A sample of three files examined contained details of what people like to do. Activities recorded in the activity plans include armchair exercises, books, puzzles, musical bingo and playing cards. There is a chart to monitor in-house activities on a daily basis and staff write comments about the activity and if the person enjoyed it. There are photographs and evidence that people undertake outdoor activity. Community activities such as 10 pin bowling, swimming or shopping and going out for coffee are also recorded. It was evident that these external activities Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 14 gave great enjoyment and promote self-confidence. There is evidence in documents that people living in the home go on holiday to Roydon Mill and Centre Parcs. On the day of the inspection the majority of the people living in the home were not at home and were out at day centres, college or pursuing a social activity. Staff were engaging well with those few people that were at home. One person was out in the garden reading a book. The atmosphere was relaxed and people were enjoying socialising with each other and with members of staff. It was evident from looking at the care plans and from speaking with three people who live at Berecroft that they are encouraged and supported to be part of the local community. The ethos of the home is for daily routines to be flexible so that people are able to choose what they want to do. People living in the home have complex needs and some have difficulties with communication, therefore they are unable in the main to discuss their likes, dislikes and wishes. The acting managers’ explained that over the years they have developed a good knowledge of what people like and dislike by their reactions and their individual ways of expressing pleasure or dislike, sometimes by trial and error. This information helps staff ensure people’s choices are taken into consideration. Berecroft tries to create a family atmosphere and meal planning is very much as in any small household. Staff spoken with said that there is not a rigid plan, there is a menu, but staff check what people want for dinner on a daily basis according to what they are doing. Records examined confirm that there is a good variety of home cooked food available. On a tour of the premises, food stocks were seen to be plentiful and of good quality. Records examined show that, if anyone has specialist needs around nutrition, the dietician is involved in planning and advising on appropriate meals. People are supported by staff, if they are able, to do there own shopping. Care staff and the managers’ confirmed that each cottage undertakes their own shopping and in the cottage sampled, two of the people living at the home are involved in the weekly shopping and budgeting. Within the menu planning consideration is taken of special diets i.e. diabetics and meal times are planned to suit the people living in the home with the main meal of the day in the evening, the only exception being on Sunday when the main meal is at lunchtime. Staff spoken with state that people in the home make choices regarding their daily lives and see them as central to the care provided. Staff see themselves as marginal and are there to support and encourage independence. The manager said in the AQAA “Individuals are supported to an active social life within the town and local community, their are opportunities to access the Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 15 local colleges, resource centre, social clubs, theatre and cinema. Individuals are supported to find paid employment” Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standards 18, 19, and 20 and quality in this outcome area is good. People using the service can expect to receive personal and healthcare support that meets their needs. The home has systems in place to ensure the safe administration of medication and the protection of the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit we were able to observe staff working around the home supporting people and ensuring that at all times their privacy and dignity was upheld. As we looked around the home it was clear that there are a range of aids and adaptations within the home to enable the people living at Berecroft to be supported in their independence. Care plans examined contained ample detail to ensure people receive the support they need in ways that they wish. “amend the independent living Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 17 skills to more realistic tasks around the home due to poor short term memory and concentration span”. One plan details ways to help the person’s emotional well being, such as bathing in the evening and playing music to help the person relax. On the day of the inspection medication records and storage was examined. Medicine Administration Record (MAR) sheets were generally well completed, there were three gaps found in the recording. The cupboard used for storing medication would benefit from being better organised. The medicine cupboard is old and, although securely fixed to the wall in a room that is accessible by people living in the home the lock is robust. Consideration should be given to how medication storage could be improved. The manager says in the AQAA that “The home is supporting individuals to access their heath needs by attending the local medical centres, where possible making their own appointments, using other Health facilities such as NHS Walk-in Centre, Gaylands House (Sexual Health Clinic); support individuals to discuss and identify their health and emotional support needs in a confidential manner. Support and empower individuals to use local facilities such as hairdressers, swimming pool, and gym. This creates social networks for individuals”. Staff spoken with said that they are happy to be working at Berecroft and that they are able to follow the written directions regarding people’s care. One member of staff confirmed that “the care plans are easy to follow and I know what care to give people”. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standards 22 and 23 and quality in this outcome area is good. People who live at Berecroft are well treated and listened to, with complaints and adult protection procedures in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home operates a robust procedure for dealing with complaints and records them appropriately. The manager says that the complaints procedure is an agenda item in staff meetings and the manager said that staff is reminded of how to deal with complaints [and] to be open and honest when they have problems between one another. There have been two formal complaints recorded since the last inspection. These issues are well recorded and dealt with in a timely and professional manner. On the day of the inspection we discussed safeguarding procedures with four members of staff (two carers and the two acting managers). The policies and procedures for safeguarding adults are available and give clear guidance to those using them, the staff spoken with were able to demonstrate that they knew when incidents need external input and who to refer the incident to. Staff said they would report to the managers but were unaware whom they should contact outside the management structure of the home. People did not know what to do if they received an allegation about either the acting manager or the deputy manager. This lack of understanding of links with external agencies and how safeguarding procedures work poses a potential risk to vulnerable people and must be addressed by the management team. The Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 19 home has had two safeguarding issues raised and records show that the managers dealt with them using the appropriate procedures and the safety of the person was of the highest priority. The manager said in the AQAA that “Swift recognition and action to complaints; positive reception to complainant, so they feel able to complain, appropriate investigation and then feedback to complainant. Timely responses to any POVA issues” Personnel records examined confirm that staff undergo Criminal Record Bureau (CRB) checks before commencing employment and the AQAA states that “all new recruits are provided with POVA booklets when carrying out induction training”, so staff are fully aware of their responsibilities around safeguarding vulnerable people. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standards 24 and 30 and quality in this outcome area is good. Generally people living in Berecroft benefit from an environment that is maintained and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager says in the AQAA that “We provide a homely individualised environment; we encourage service users to make their bedrooms their own. We promote independence by supporting service users to attend to their own cleaning of their home and bedrooms, laundry etc”. A tour of the premises was completed at the visit and each cottage was light, bright and airy. Within each cottage there is a kitchen and laundry facility, which enables the people living at Berecroft to participate in these tasks and skills, as they are able. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 21 As of the previous inspection furnishings, fittings and furniture are of a decent standard and were individual to each cottage and to the people living in the cottages. As previously stated the maintenance and decoration of the home is stated to be ongoing with both a maintenance management company appointed by Essex County Council and a Gardener/Handyman employed. The property was well maintained with action taken or programmed as soon as issues were noted. Bedrooms are all decorated to individual tastes. The deputy manager explained that some people were able to indicate their preferences around colours but others were not able to communicate on this level. The management team and staff have got to know people and choose for them using past experience of things they appear to prefer. All bedrooms are decorated to a good standard and, as in the communal areas; furnishings are of a good quality. Staff spoken with felt that the home was in need of a general redecoration and that they felt that the home “could do with some investment to make people a bit more comfortable”. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standards 32, 34, and 35 and quality in this outcome area is good. People living in Berecroft can be confident that their needs will be met by a competent, well trained staff team. People can be confident that the recruitment checks help to employ appropriate staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing rota seen on the day confirmed that the home has enough staff working there both during the day and the night. By having the correct amount of staff on duty the home is able to provide people with a good quality, flexible team of staff. Berecroft maintains a thorough and robust staff recruitment procedure. The home has frozen its staff recruitment and it will use agency staff to bridge any gaps in staffing for the time being. If recruitment were to take place staff confirm that the people who live at Berecroft are involved in the selection process, for the home involves their advocates in this process. All of the staff spoken with on the visit confirmed that they were put through a rigorous Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 23 recruitment process before starting work that ensures the safety of the people living there. Berecroft provides an effective training programme to ensure all staff have the necessary skills. Records examined confirm that staff receive a range of training including Health & Safety, POVA refresher training, Food Hygiene, Infection Control and Care of Medicines. Specific training around health related issues is also given. A well-trained staff team ensures that people living in the home receive appropriate support to meet their needs. The acting managers state that the training programme needs to be developed and updated to make sure that all staff employed in the home has had mandatory and refresher training. The staff records held in the home confirm that over 50 of the staff team have achieved their NVQ Level 2 qualification. This ensures that people living in the home receive care from individuals who are well trained. Staff who spoke to us all made positive comments about the training they receive. Comments include, “The training I’m given is above and beyond the minimum requirements”, “The training courses that we are all put on are very good”, “[they] always update staff with relevant training” and “This home makes sure all staff have the right training they need to do the job”. Records examined confirm that staff supervisions are being carried out. Staff spoken with on the day of the inspection visit feel well supported. Staff who are well supervised and receive appropriate support from management perform better and this improves the service for people who live there. The manager said in the AQAA that: “Staff supervision and support is maintained by regular meetings. Open door policy so that staff can discuss issues and concerns as they arise; maintain minimum staffing levels; adopt a positive approach to staff development and training, with a commitment to support staff to achieve NVQ Awards and other training”. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We inspected standards 37, 39, and 42 and quality in this outcome area is good. Berecroft is competently managed and run in the best interests of the people who live there. The health and safety of people living and working in the home is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As previously described the previous manager resigned from the service. The two acting managers have a wealth of experience. One of these used to manage the home and visits the home almost every day, while the other acting manager has worked in Berecroft for six years in a variety of roles. The acting managers are well aware of the regulatory requirements of the service and are confident that they achieve these. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 25 There are no records of meetings with people in the home where their opinions are sought. The acting manager confirmed that the views of people are an integral part of the service they provide and are gathered informally. There are no surveys or information gathering process used in the home. However, people spoken with who are generally able to express an opinion, say that the management and staff listen to them. Overall people living in Berecroft cannot be confident that their opinions on the service are sought and acted upon. This process needs to be formalised in writing, the views of people need to be recorded and evidence that people’s opinions and issues are responded to. As at the last inspection, Health & Safety records examined were found to be in good order and up to date. A sample of records was examined on this visit and there is evidence that Portable Appliance Testing is carried out, hoists, heating and fire equipment also have regular maintenance checks. Records examined also confirm that staff have received infection control training and there are COSHH (Control of Substances Hazardous to Health) assessments in place. People living in the home are protected by the robust processes in place relating to health and safety. Staff spoken with said that they had received training relating to people’s safety and this has made them feel confident that they are providing people with a service that decreases and risks and makes people safer. The manager said in the AQAA that: “Identification of management roles and who is responsible to undertake certain duties; role modelling of core principles such as motivation and professionalism. Developed good working relationship and links with other agencies and professionals. A motivated team who strive to develop them selves and others to good professional attitudes with flexible approaches to new initiatives and ideas”. Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 27 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 YA23 Regulation 12 (1) (a) Timescale for action The management team must 31/08/08 ensure that all staff understand the links with external agencies and how safeguarding procedures work. Staff must be made aware of whom to contacts external to the organisation in the event that an allegation is made against the management team. The home must implement the 30/09/08 process for gathering information on people’s views, analyse the information and respond to any issue that requires action. This requirement is outstanding from: 31/07/06 and 19/10/07 Requirement 2 YA39 24 (1) (a) (b) (2)(3) 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 YA20 Good Practice Recommendations People who use this care service should be assured that DS0000034845.V368177.R01.S.doc Version 5.2 Page 28 Berecroft Home medication records are accurate and well maintained. 2. YA37 The service recruits to the manager post Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Berecroft Home DS0000034845.V368177.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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