Care Home: Berkeley House

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What the care home does well The staff have a good understanding of Person centred planning and people are supported to achieve the things in their lives that are important to them. There are plenty of opportunities for educational and life skills activities at the on site resource centre. Staff support people to access any colleges or employment outside of the home if they wish. The staff are well trained and have a good understanding of people`s needs. There is a stable staff team and limited use of agency staff. The home supports people to give their views of the service and to have a say in how the home is run. Lots of the policies and information have been produced using pictures to help people understand better. What has improved since the last inspection? What the care home could do better: The Statement of Purpose needs to be changed to give people up to date information about CSCI inspections. Medication records need to be signed by staff consistently and the Manager must introduce a system to ensure this happens.Some work is needed in some of the bathrooms to make sure they can be kept clean and hygienic. Some of the bath panels need replacing. The carpets in the Granary need cleaning. People in the home would benefit from more staff gaining their NVQ award. The home does not currently have a registered Manager and the new Manager should apply for this as soon as possible. CARE HOME ADULTS 18-65 Berkeley House Lynsted Lane Lynsted Sittingbourne Kent ME9 0RL Lead Inspector Jo Griffiths Key Unannounced Inspection 11th October 2007 09:00 Berkeley House DS0000023892.V352595.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 Berkeley House DS0000023892.V352595.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. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Berkeley House Address Lynsted Lane Lynsted Sittingbourne Kent ME9 0RL 01795 522540 01795 520430 berkeley@regard.co.uk 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) The Regard Partnership Ltd Post Vacant Care Home 23 Category(ies) of Learning disability (23) registration, with number of places Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one service user over the age of 65 years. Date of last inspection 1st June 2006 Brief Description of the Service: Berkeley House is a registered care home for 23 adults with learning disabilities. It is one of a group of homes owned and managed by The Regard Partnership. The home can now only accommodate 19 service users and the Manager needs to apply to CSCI for a variation to the registration of the home to reflect this. The home is situated in the village of Lynsted, roughly one mile south from the A2 at Teynham. The service is provided in three separate listed buildings set in large grounds. The Granary provides accommodation for four service users. The Windmill has five service users. The main house, The Bakery, has current accommodation for ten service users. The Granary and The Windmill are self-contained and are staffed independently from the main house. Each house has its own fenced area of garden. The home has two vehicles that are used as required to provide transport to local services and amenities. Teynham is on a bus route and has a main line railway station. The fees charged for this service range from £717 - £2189.25 per week. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of this service. The inspector visited the home between 10.30am and 5.00pm on 11th October 2007. During the inspection some of the people that live at the home were asked their views, some of the staff were spoken with and some of the important records were seen. The inspector also had a look around the three houses and spent time talking with the Manager about the service. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose needs to be changed to give people up to date information about CSCI inspections. Medication records need to be signed by staff consistently and the Manager must introduce a system to ensure this happens. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 6 Some work is needed in some of the bathrooms to make sure they can be kept clean and hygienic. Some of the bath panels need replacing. The carpets in the Granary need cleaning. People in the home would benefit from more staff gaining their NVQ award. The home does not currently have a registered Manager and the new Manager should apply for this as soon as possible. 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. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 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 Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are provided with the information they need to make an informed decision about moving to the home. They have a full assessment of their needs before they move and are assured their needs will be met. EVIDENCE: The Statement of Purpose and Service User Guide give people the information they need about the service. The Service User Guide is given to people when they move into the home and has been designed using symbols and pictures to aid people’s understanding. One minor amendment is needed to the Statement of Purpose as it still reflects that CSCI visit the service twice a year. This has changed since the introduction of ‘Inspecting for Better Lives’ and the Manager should update the document to reflect this. Further information about this can be found on the CSCI website. People moving into the home have an assessment of their needs before they move in to ensure the home can fully meet their needs. The assessment of needs for a person recently moving to the home was seen. This showed that all areas of need had been considered and that the home had planned how to meet the needs in the care plan. The Manager is in the process of updating the Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 9 assessment of needs for all the existing people in the home to ensure any changes in needs are reflected in the plan. The home accommodates people with a range of additional needs including physical disabilities, diabetes, and communication difficulties. The home state they able to support people from a variety of diverse backgrounds. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have an individual plan that ensures their assessed needs are met. They are supported to make decisions about their lives and to have a say in the running of the home. People are supported to take reasonable risks as part of an independent lifestyle. EVIDENCE: Each person has an individual plan that addresses all the needs identified by assessment. The individual plans are detailed and regularly reviewed to ensure they are up to date. The individual plans contain a substantial amount of information, some of which is repeated from other areas of the plan. The Manager plans to review the individual plans to ensure they are easy for staff to access and follow. Work is also being done to make the plans more person centred and accessible to the users. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 11 The Management team and staff have a good understanding of person centred planning and how to support people to achieve their dreams in life. This year two people were supported to achieve their dreams. One was to attend a James Bond event and one was to see their favourite football team play. Planning work is done with the individual using a variety of person centred tools. It was discussed with the Manager the benefits of referring to people’s hopes and aspirations for the future within the individual plan. It was evident through the Person centred planning results and the individual plans that people are supported to make their own decisions in life as far as they can. Six monthly review meetings are held for each person and they are supported to plan any goals they have for the future. The minutes of the review meetings are produced in a user friendly format and evidence that the person has been involved in the review. There are monthly house meetings in each of the homes. This is an opportunity for people to give their views of the service, make suggestions and requests and to raise any concerns. People that have limited communication skills are being supported to use ‘traffic light’ coloured cards to indicate their views. The minutes of the most recent meetings were on display on the service users notice boards. They are produced in picture and symbol format. Each person also has a monthly meeting with their keyworker, which is a 1-1 opportunity to discuss anything they wish. There is a monthly newsletter for the home and people living in the home have been contributing to the production of these. People are supported to take risks in order to lead fulfilling lifestyles. Risk assessments are completed for any activities the person wishes to undertake that are perceived to have an element of risk. Risk assessments have also been completed for general activities in the home such as cooking, bathing and the general environment. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported to undertake the activities of their choice. There are sufficient opportunities for educational and leisure activities. People are supported to gain employment if they wish. People in the home are aware of their rights and responsibilities. They are supported to make and maintain friendships and appropriate relationships. People in the home enjoy their meals and mealtimes. EVIDENCE: Each person has a plan of activities for the week that has been written in consultation with them. Most of the structured activities are provided by the new resource centre on the site. This includes sessions on Art, Crafts, Computing, cookery, maths, English and life skills. In addition, the resource Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 13 centre arranges some external outings, for example recent trips include Leeds castle and various theatre shows. Some people choose to attend colleges in the local community and some people use Day Centres in the local towns. There are some external therapists that visit the home including music sessions and aromatherapy. When not attending education or therapeutic activities people are supported to undertake the activities of their choice. Through speaking with staff and people in the home it was clear that people lead busy lives. Staff said that people now have more opportunities to get out more. They make use of the local shops and pubs as well as travelling to the towns of Sittingbourne and Faversham for shopping trips, bowling and cinema. The records of people’s activities could be expanded to give detail about what activities they are doing and whether they were enjoyed. There is no one currently in employment but one person has expressed a wish to gain employment and is being supported to do so. People are supported to make friends and meet new people through their activities outside of the home. There are social clubs and a monthly trip to the nightclub available for people to attend. People know that they will be supported in personal relationships should they wish. People can receive visitors when they wish and most have family members to visit. One person is now being supported to meet up with his brother outside the home once a month. The Service User Guide contains the rules of the home. These are generally focussed on respect for other people and the property. People are supported to carry out cooking, cleaning and laundry duties as far as they are able and staff complete most heavy duty domestic tasks. People were seen throughout the inspection to be supported to make themselves meals and drinks when they wish. People spoken with said they enjoy the meals. Menus are managed in different ways in each of the three houses. Some people prefer to work to a planned menu with alternatives choices and some people prefer to decide what they would like on the day. Records are kept of all meals eaten to ensure people are receiving a balanced and varied diet. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are fully met. They are supported to manage their medication safely, but would be further safeguarded by tightening of procedures with regard to medication records. EVIDENCE: People’s health needs are met through the individual plan. They are given the support they need to manage their healthcare appointments and their health needs are reviewed by the keyworker. Records are kept of all appointments and interventions. Everyone is registered with a GP and dentists. Some specialist healthcare is sought through the community learning disability team as needed. Individuals’ personal care needs are discussed with them and recorded in the care plan. As the plans are being developed to be more person centred this has been expanded to include the support they do want from staff as well as anything they don’t want staff to do. People are consulted about the staff they would prefer to support them with personal care and about any support they Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 15 may need at night. There are a range of bathroom facilities available to support people with their personal care. Medication is stored safely and is only administered by trained staff. On reviewing the records two errors in signing for medication were found. The medication was checked and found to have been given, but not signed for. However, other staff had signed for medication on the days that followed, but had not picked up that the sheet had not been signed. The Manager undertook to investigate this and to review the handover procedures to ensure MAR sheets are checked. There are no service users currently managing their own medication. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People know how to make a complaint and felt hey are listened to. They are safeguarded from abuse and harm by trained staff and robust policies. EVIDENCE: The complaints procedure is in pictorial form and is displayed on all the service users notice boards as well as being included in the Service User Guide. One complaint has been received from a person living in the home since the last inspection. The person was supported by their keyworker to complete the complaints form, which is also in pictorial form, and send it to the Manager. The complaint was investigated appropriately and a response given to the complainant. There has been one complaint received by CSCI since the last inspection in relation to staffing qualifications. This was passed to the Manager to investigate. CSCI consider the matter to have been appropriately investigated and evidence supporting the conclusion of the investigation was provided. The complaint was unfounded. There have been two incidents in the home that have required a Safeguarding Adults referral. The Manager sought advice from CSCI with regard to these matters and reported the incidents appropriately. The Manager has since revisited the KCC Safeguarding Adults policy to familiarise herself and other Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 17 members of the management team with the procedures. The Manager is awaiting a response from KCC regarding the two referrals. Staff spoken with said they had completed training in Safeguarding Adults and were aware of reporting procedures in the home and the whistle blowing policy. Staff said they felt confident to report any concerns and to approach management at any time to discuss issues. Training records show that all staff have completed Safeguarding adults training and all staff have a CRB and POVA check before they work in the home. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 18 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): Standards 24, 27, 28 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People benefit from a comfortable and safe environment that meets their needs. They would benefit from minor maintenance works to bathrooms to ensure hygiene standards can be maintained. People have access to sufficient communal space, but will further benefit from unlimited access to the quiet lounge in the Bakery. EVIDENCE: The care home is made up of three houses. The bakery is the largest house, housing ten people, and has a large lounge and dining room and a new quiet lounge. The quiet lounge has been kept locked during the day and people in the home just use it in the evenings. When asked why it could not be accessible at all times the Manager said that it there was no problem with this and that it would be left open and accessible to people from now. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 19 The kitchen in the bakery was being re fitted at the time of the inspection. Provision had been made for people in the Bakery to use the kitchen in the adjoining resources centre during this time. The Manager stated that the new kitchen with be safer for people to use and more accessible for service users. It is not planned to have any lower worktops, as it is not foreseen that the environment of the home would ever be suitable for people that use wheelchairs. The Manager was concerned that the large industrial cooker is not being replaced as part of this refurbishment and that it is not felt by the Manager to be easy for service users to use. One of the bathrooms has been adapted since the last inspection to provide an easy access shower. The flooring requires sealing around the edges to avoid leaks and infection risks. The Manager stated that the maintenance department had been notified of this. All areas of the home have been redecorated and furnished to provide a more comfortable environment since the last inspection. It was noted that, due to the age of the building, some of the bedroom and communal doors are very squeaky. The Manager should ensure that people are not disturbed by the waking night staff carrying out checks throughout the night. The Granary is a smaller home for four men. This provides a homely environment for the people that live there. The home has been decorated and furnished to the taste of the occupants. The bathrooms require some minor maintenance work to replace the bath panel and re seal the edges of the flooring to avoid infection risks in the home. The carpets in the communal areas of the granary require cleaning. The Windmill provides accommodation for five people and has been adapted to provide accommodation for people with mobility difficulties on the ground floor. Again the environment has been decorated and furnished to provide a comfortable home for the people that live there. The bathroom requires some minor work to ensure there are no cross infection risks, including replacement of the bath panel. The shower room has been refitted to provide easier access for people with limited mobility. The gardens have been fenced to provide private garden space for each house. The gate to the Windmill has been designed to open both ways to allow people that use wheelchairs to be able to use it independently. Designated smoking areas have been introduced outside the buildings. There is a service users notice board in each of the houses that displays minutes of the service users meetings, information about activities, the complaints procedure and the quality audits carried out by the Regard Partnership. There are also some picture boards in the home to help people plan their activities. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 20 A new resource centre on site was opened in the summer. This contains Art and craft rooms, a skills kitchen and a computer room. A timetable of sessions is in place for during the weekdays and people can access the facilities in the evenings and at weekends. E mail and internet access is not currently available in the resource centre and the Manager is making arrangements for this to be set up. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 21 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): Standards 32, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People benefit from a staff team that are trained and supported by their managers. They would benefit from more staff obtaining the NVQ award. People in the home are protected by the staff recruitment procedures in the home. EVIDENCE: Staff have completed all the key training courses they are required to do in order to safely and effectively support people in the home. In addition they have also undertaken training in other areas including Person centred planning, epilepsy, risk assessment, autism and sexuality. The Manager has a matrix of staff training in order to monitor when updates are required. Staff training needs are discussed with them through the supervision process. Staff members spoken with said they felt the training they received was useful and that the organisation are supportive with regard to their training needs. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 22 Some of the staff have completed their NVQ award and some are working toward this. New staff have been registered to begin the qualification and the Manager is working to achieve the recommended minimum standard of 50 of the staff team being qualified. The recruitment records for three new staff were inspected. These showed that robust checks were being made prior to employment including CRB/POVA checks and two written references. There was evidence that staff eligibility to work in the UK is being checked and where visa renewals are required this is being monitored. Evidence in staff files showed that they have a supervision session with their line Manager at least every two months. Staff spoken with said they felt well supported and confident that they could approach any of the management team to discuss any issues. Feedback from staff members included positive comments about the changes that have taken place in the home over the last year. They said that the home feels calmer and that people are being supported to get out more. Staff said they enjoyed working at the care home. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 23 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): Standards 37, 38, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well run by a competent manager, but service users will benefit from the Manager becoming registered with CSCI. People are consulted on their views of the service as part of regular quality monitoring of the home. The health and welfare of people in the home is protected. EVIDENCE: There is a new Manager in the home who has been promoted from deputy Manager. She has been working in the home for many years and has a good understanding of the needs of the people that use the service. During the Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 24 inspection the Manager demonstrated an understanding of the Regulations and National Minimum Standards. The Manager also demonstrated she has good leadership skills and clear direction of the home. Staff and service users spoke highly of the Manager and management team saying they felt them to be honest and approachable. The new Manager is working toward the NVQ award in both Care at level 4 and the Registered Managers Award. She has not yet applied for registration with CSCI but plans to do so within the next few weeks. The deputy Manager has also been working at the home for many years. She holds an NVQ 3 in care and is working toward the NVQ 4. There is a team of senior carers that work on the rota and supervise and support staff. The Manager and Deputy Manager are available in the on site office for people to talk to Monday to Friday. There is an on call system in place for out of hours. The Manager stated that she visits each of the houses several times a day to chat with staff and service users and to monitor the quality of service. All accident reports, monthly summaries, health and safety checks and meeting minutes come to the Manager as part of her quality monitoring. During the inspection the Manager was working to address the issue of medication records reported under standard 20 above. They are a number of opportunities for people in the home to share their views of the service and to raise any concerns. There are monthly service users meetings in each house, monthly meetings between each person and their keyworker and 6 monthly care review meetings. The Regard Partnership carries out monthly audits of the home under regulation 26 and surveys service users for their views once a year. The Manager is planning to introduce relatives meetings. Health and safety audits are completed by staff and risk assessments are in place for individuals and the general environment. Equipment is serviced annually and fire safety systems are checked weekly. There were no serious Health and Safety concerns found during the inspection. Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 25 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 2 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 2 25 X 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 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 2 X 2 3 3 X X 3 X Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5 Requirement The Statement of Purpose must be amended to accurately reflect the role of CSCI and the ‘Inspecting for Better Lives’ programme. Accurate records of medication administered in the care home must be maintained. The bath panels in the bathrooms must be replaced and areas of flooring that require sealing addressed to reduce the risk of infection in the home and to provide a more pleasant environment for people to use. The carpets in the Granary must be cleaned. The registered provider must, unless they intend to carry out day-to-day management of the home, ensure an application is made to CSCI for a Registered Manager for the care home. Timescale for action 30/11/07 2 YA20 13(2) 31/10/07 3 YA24 YA30 23(2)(d) 30/11/07 4 YA37 8(1) 30/11/07 Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 27 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 YA7 Good Practice Recommendations It is recommended that the Person centred planning work that has been done with service users be reflected in their care plans. It is recommended that the Manager ensure that service users are not disturbed at night by squeaky doors. It is recommended that people in the bakery are not restricted in the use of the quiet lounge. It is recommended that the fitting of the old industrial size oven in the service users kitchen in the Bakery be reconsidered. 4 YA32 It is recommended that at least 50 of the staff be qualified to NVQ level 2 or above. 2 3 YA24 YA28 Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Berkeley House DS0000023892.V352595.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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