Inspection on 05/10/06 for Barclay Gardens

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Barclay Gardens 07/08/09

Barclay Gardens 21/08/07

Barclay Gardens 16/01/06

Barclay Gardens 27/09/05

Barclay Gardens 09/12/04

Barclay Gardens 06/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Barclay Gardens Barclay Gardens Wellington Road Telford Shropshire TF2 8AB Lead Inspector Karen Powell Key Unannounced Inspection 5th October 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barclay Gardens Address Barclay Gardens Wellington Road Telford Shropshire TF2 8AB 01952 605321 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) www.coveragecareservices.co.uk Coverage Care Services Ltd Pauline Tremellen Care Home 40 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (20) of places Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 40 Older People, of whom 20 may be suffering from dementia. 16th January 2006 Date of last inspection Brief Description of the Service: Barclay Gardens is a purpose built care home for older people located in Donnington, Telford. The home became operational on 9th April 2003. The home can accommodate a maximum of 40 older people, 20 of whom may have Alzheimers related illnesses. The home is owned by Bromford and Corinthian Housing Association and leased to Coverage Care Shropshire Limited who provide the management and staff. The building also accommodates a large day centre and 24 independent living flats also for older people. The restaurant accommodates all residents (if they choose) and non-residents attending the site. From 15th October 2006 the home will be a no smoking home. The weekly fees are 412.00 – 450.00 additional charges are made for toiletries, hairdresser and private chiropodist. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and was carried out by one inspector. The visit lasted six hours. The inspection covered all twenty key standards and standards 11 and 36 of the care homes for older peoples national minimum standards and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The inspection included talking with service users, the manager and members of staff on duty, case tracking service users, observing work practices, looking at a number of records and a tour of the home. The inspection was positive with almost all the key standards of the national minimum standards for older people being met and in several standards exceeded. What the service does well: What has improved since the last inspection? The home have addressed the two requirements made at the last inspection. The home has adopted the guidelines of the Liverpool Care Pathway and Gold Standards Framework to develop the end of life care provided to service users. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 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. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 All service users are appropriately assessed prior to moving into the home by a suitably qualified person. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of five service users were examined as part of the case tracking process. There was evidence that all service users individual needs had been assessed prior to moving into the home. Assessments were seen to be provided by local funding authorities. Coverage care private assessments had been undertaken for those service users who are funding their own placements. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 There is a clear care planning process in place, where service users health and personal care needs are set out, with evidence of regular review. The systems for management of medication in the home are good and followed by staff that are trained in the safe handling of medication. The principles of respect, dignity and privacy are put into practice by the care team. End of life care has been developed using current best practise guidelines. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a plan of care. Evidence of regular reviews were seen and changes reflected within the plan. The requirement made at the last inspection carried out on 16th January 2006, which, stated all care plans must be reviewed by care staff at least once a month, had been met. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 10 Care plans reflected relevant information that would be helpful for staff when providing care and support to individuals. Service users’ preferred terms of address, likes and dislikes were recorded on the care plan. Risk assessments were in place where appropriate. Five service user care plans were examined as part of the care planning process. Through examination of individual records, discussion with service users and staff it was apparent that individual service users personal, health and social care needs are being met. District nurses visited to carry individual treatments to service users during the inspection. These visits along with visits by GP’s were recorded on individual files. During the inspection a relative of a service user who had been transferred to nursing care visited the home, feedback from the individual was positive in relation to the care provided by staff at the home. Service users were observed to be entertaining guests in their rooms. Staff were respectful and professional towards service users and their visitors during the inspection. A brief review of medicine storage provision and medicine administration records demonstrated the home’s practices meet the guidelines of the Royal Pharmaceutical Society. The requirement made at the last inspection carried out in January regarding that “staff adhere to the policies and procedures for receipt, recording and administration of medicines” was considered to be met at this inspection. A visit by a pharmacy technician from The Primary Care Trust medicine management team took place during the inspection. Service users who wish to maintain control over their medication are assessed and where this has been agreed, documentation supports such a decision. The decision is reviewed on a regular basis. Since the last inspection the manager and staff have been working with other health care professionals in developing end of life care. The manager and staff have used the guidelines of the Liverpool Care Pathway and Gold Standard Framework to develop care and support, which as stated in the service user guide includes “maintaining dignity, autonomy, having choices and receiving appropriate pain relief as well as emotional and spiritual support”. Supporting documentation was shared with the inspector, which appeared comprehensive. There were no service users living at the home in receipt of end of life care for the inspector to observe the support in practise. The manager stated that feedback from district nurses was positive and good relationships are in place between multi disciplinary professionals. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Service users are able to choose their life style, social activity and keep in contact with family and friends. Service users receive a healthy, varied diet according to their assessed requirement and choice. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are encouraged and enabled to personalise their own rooms, evidence of this was seen during a tour of the home. Visitors were seen coming and going throughout the inspection. The inspector had the opportunity to speak to two visitors, one relative and one advocate. Both were complimentary of the services and care provided by the home. Service users and staff spoke to the inspector about activities that take place in the home. The inspector observed some service users taking part in a planned activity on Bracken unit. A visiting singer performed during the afternoon, and service users appeared to enjoy the entertainment. Pictures were displayed around the home of activities that have taken place since the last inspection, these included a trip to Llandudno and a garden party. The hairdresser was available to service users during the visit. One service user Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 12 has made flowering plant pots for the garden and won a certificate for their achievement. An information stand is available in the main reception area. Information was varied and appropriate for the service user group/relatives/friends using the home. Information included the last CSCI inspection report in Punjabi, the manager stated she had obtained this for a Punjabi speaking service user who had entered the home. Service users were complimentary about the quality and choice of food. It was stated by the manager that a new catering has been appointed. Dining areas visited at the time of inspection were clean and well presented. A separate restaurant is available for all to use and service users can take relatives/friends for a meal in pleasant well maintained surroundings. The home has achieved the gold Healthy Eating Award for the second year running. Service user meetings are held on a regular basis with copies of the minutes available in all units in large print. These were shared with the inspector. The home has a therapy room used for massage and exercise, a hairdressing salon and a well stocked shop. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is a clear complaints procedure in place. Polices and procedures are in place to protect service users from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A clear complaints procedure is in place and is well published in information provided to service users and their relative/representative at the beginning of their stay. There have been 15 complaints received and dealt with through the homes own complaints procedure since the last inspection. All had been dealt with in line with the complaints policy and were recorded in a central complaints log, detailing the complaint, action/investigation and outcome of investigation. There has been one complaint received at CSCI since the last inspection, which was referred to the home to address through the homes internal complaints procedure. All staff are trained in adult protection. Two new staff that are in the process of induction training competently explained what action they would take if they suspected any issues of abuse or concerns to the inspector. The home has all necessary documentation in relation to the protection of vulnerable adults and this subject is included in staff training. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 14 Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. There is a well equipped laundry room. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users are encouraged to use the home as their own. This was seen during the home tour. The home is purpose built designed into small units with dining and seating areas. All bedrooms are single with en-suite facilities, ample space and equipment is in place to meet the individual needs of the service users. All rooms have a call bell facility. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 16 The home was clean and well maintained. Laundry facilities were seen during the tour and were well organised and equipped to be able to manage the laundry of 40 service users. Service users clothing appeared clean and well laundered. The Primary Care Trust carried out a recent infection control care home audit on 5th May 2006. The home demonstrated good infection control practices and have implemented the recommendations made as a result of the audit. Random water tests showed temperatures were satisfactory and did exceed more than the recommended 43°C. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 There is a robust recruitment procedure in place where staff are properly vetted before commencing post. Staff in the home are trained, skilled and in sufficient numbers to meet the current needs of the service users living at the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was stated by the manager that there is currently a full staffing complement to the home. There have been a number of vacancies, which have now all been appointed to. During this period of recruiting the home have not used agency staff and have covered the hours between the team to ensure continuity. Interviews took place the day before the inspection for a catering manager. On the day of the inspection staffing levels were satisfactory. There is a robust recruitment procedure in place. The files of three new staff were examined to monitor recruitment practices and contained all the required elements. Clear interview notes are kept on file. More than 62 of care staff are qualified to NVQ level. All staff complete a thorough induction programme linked to the skills for care council. A sample of a newly recruited member of staff workbook was seen by the inspector. The member of staff had also attended moving and handling, care planning, coping with loss infection control and protection of vulnerable adult training. In addition to the homes induction all staff attend head office for a two day Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 18 company induction. The training plan for the home was shared with the inspector and a variety of training including mandatory and specialist training. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. A qualified and competent individual manages the home and there are clear lines of accountability in place. There is an effective quality assurance process in place, which includes service users and families. Service user financial interests are protected by the homes policies and procedures. Staff receive supervision, however this has not always been at the required frequency. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 20 There is a qualified competent manager in post who has over twenty years experience in the caring profession. Since the last inspection she has completed the NVQ level 4 in care and the registered managers award. Through discussion with the managers and staff it was demonstrated they have a clear understanding of the needs of the service users living at the home. There are clear lines of accountability in place at the home with an openness to discuss any issues with the manager. The deputy manager is covering an acting up post at another Coverage Care home in Shropshire. There are two assistant managers who support the manager, along with an administration assistant. A formal service review is carried out at the end of a persons stay or at regular intervals by head office and the results are published in the service users’ guide. Where possible service users are encouraged to handle their own finances, locked draws are provided in each bedroom for security. The financial record of a service user who was followed for case tracking purposes was checked. Records and receipts were seen and a check of money held was correct and stored in safe keeping in individual wallets. All staff receive supervision however a random sample of three long term members of staff supervision records were checked. Two out of the three staff had not had their supervision at the required frequency. Matters pertaining to the last fire officers inspection were discussed with the manager and reported to have been addressed. A completed risk assessment for safe working practices within the home is in place. COSHH safety data sheets were in place and a random check was found to be satisfactory along with a brief examination of the COSHH risk assessment. Records in relation to the servicing of equipment were seen and found to be up to date. Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP36 Regulation 18(2) Requirement Care staff must receive formal supervision at least six times a year. Timescale for action 05/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Barclay Gardens DS0000044626.V296993.R01.S.doc Version 5.2 Page 24 - 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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