Inspection on 06/08/08 for Barclay House

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Barclay House 06/09/06

Barclay House 18/10/05

Barclay House 06/05/05

Barclay House 18/10/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Barclay House St Peter`s Road Seaford East Sussex BN25 2HS Lead Inspector Melanie Freeman Unannounced Inspection 6th August 2008 09:30 Barclay House DS0000032162.V369007.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 Barclay House DS0000032162.V369007.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. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barclay House Address St Peter`s Road Seaford East Sussex BN25 2HS 01323 873421 01323 873422 barclayhouse@seeability.org 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) SeeAbility Miss Amanda Honour Holmes Care Home 9 Category(ies) of Sensory impairment (0) registration, with number of places Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Sensory Impairment (SI). The maximum number of service users to be accommodated is 9. Date of last inspection 6th September 2006 Brief Description of the Service: Barclay House is a purpose built home, registered to provide residential care and support for up to nine adults who are blind or partially sighted and who may have additional special needs. The service is situated on a campus, which also includes two recently converted, self-contained flats for more independent living and an Activities and Resource service. All accommodation for residents is provided on the ground floor and consists of single rooms with en-suite facilities. Communal areas include a spacious, open plan kitchen and dining room and a large and comfortable lounge. The building is designed specifically for people who have visual impairment problems. It is safe, accessible and fitted throughout with all necessary adaptations and specialist equipment, including assisted baths and hoists. To the rear of the premises, there is a pleasant sensory garden laid to lawn with raised flowerbeds and a patio area. Seaford town centre with its shops and access to bus and rail routes is approximately half a mile away. Information about the service, including the recently updated Statement of Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 5 Purpose, Service User’s Guide and CSCI reports is made available to prospective residents or their relatives, on request, as part of the admission process. The annual base fee, as of August 2008, is £65,490 this price includes 15 hours at the on site Activity and Resource service. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 6 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. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Barclay House will be referred to as ‘residents’ in accordance with their preference. This was a key inspection that included an unannounced visit to the home and follow up contact with a visiting professional. At the time of this visit there were 9 residents living in the home and feedback from those spoken to and those who completed a survey were mostly positive. One resident said ‘I love living here’. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with the registered manager. The main focus of the inspection was to focus on the quality of live that resident’s experience. The required Annual Quality Assurance Assessment (AQAA) was completed and returned prior to the inspection visit and information from this has been used to inform this report. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from four residents and five staff members. What the service does well: Barclay House provides an individualised service to the people that live there with the emphasis firmly on skills development and increasing independence for individuals. The home is well managed and provides a high quality care and accommodation for people with a sensory impairment. The home has a comfortable, relaxed and welcoming environment, which is promoted through skilled staff and an inclusive management style. Effective communication and consultation systems enable residents to be directly involved in developing and reviewing their individual care plans as well as many decision-making processes within the home. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 7 All residents are provided with a copy of the ‘Charter of Service User Rights’, which forms the basis of care provision at Barclay House and underpins the ethos of the home and the work undertaken there. The manager and staff are clearly committed to maintaining high standards of care and support and are looking at ways to improve resident’s life experiences. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Barclay House DS0000032162.V369007.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 Barclay House DS0000032162.V369007.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): 1 and 2 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents have all the required information available to enable them to make an informed choice about the home and if they want to live there. The admission procedure ensures that residents are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective residents have the opportunity to visit the home and know that it is able to meet their individual care and support needs. EVIDENCE: A statement of purpose and service user guide is available to all residents prior to admission in the form of a handbook; this promotes an understanding of the services in the home and what it can provide. These documents are available in Braille if needed and staff spend time with people to ensure an understanding of its contents. Although both these documents were available on request in the home it was recommended that it was displayed and available at the front entrance where information regarding other Organisations are held. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 10 Admission practice followed in respect of the last two admissions to the home was reviewed. This confirmed that the admission process is lengthy and involves a multidisciplinary approach with key people from the home and the views of the prospective resident taken into account. It is important the admission is a suitable one for the prospective resident and other people in the home and it was evident that this was central to the process. The documentation used to record the process however was not very clear. The registered manager advised that the admission procedure is being reviewed and that a working party is currently working on this. She explained that the current arrangements have been in place since 2004 and are in need of an overhaul. This will take into account the need for clear documentation of the admission process throughout. Barclay House DS0000032162.V369007.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): 6, 7 and 9 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each resident has a plan of care that enable staff to meet the assessed support needs of residents in a structured and consistent manner. Systems for consultation and participation are effective. Residents are treated with respect and are encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: The care documentation of two residents were reviewed as part of the inspection process. Each had an extensive file that contained detailed information about individual needs and risks. These files did however include a lot of information that was old and it was therefore difficult to find the current and relevant information for each individual. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 12 The care plans on the whole were well written giving guidance to staff on how to care and support the resident. They reflected an individual and person centred approach to care and was documented within ‘care support plans’. In addition separate guidelines are available on how to support individuals in completing daily living activities and skills, for example laundering personal items. This promotes independence within a therapeutic environment. The registered manager explained that residents do not sign the plans of care, as she believes it is not appropriate for them to sign something that they cannot read. She assured that full discussions do take place, and acknowledged that a way of evidencing this consultation and agreement needs to be recorded more clearly. The deputy manager explained that further work is being completed on the development of person centred plans of care and a government funded scheme has been accessed to work along side the residents to formulate these. Regular formal reviews are completed. The resident is central to this process attending any meeting with appropriate relatives, care manager, key worker and home manager. Reviews completed are used to update the plan of care. Detailed daily records are recorded and these reflect the daily activity including any social events attended and an assessment of the residents well being. Identified risks are assessed and recorded in the care documentation. The ethos of the home is based very much on promoting independence and the risk assessments sampled support this. Residents are given confidence to travel by bus and to walk independently to local community resources and services. Residents are involved in all decision making and this was observed during the inspection visit when residents were encouraged in making their own mind up on a number of matters. Examples of this include what they wanted to buy on a shopping trip and what they wanted for lunch. Staff work hard to promote positive decision making which some residents find difficult. One said that she ‘preferred to be told what she can do in the afternoon’. Barclay House DS0000032162.V369007.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): 11 and 17 People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity for personal development, and to take part in appropriate leisure and community activities. Individual rights are respected and dietary needs are met. EVIDENCE: Residents at Barclay House lead a very active life that includes social and life style activity. They are supported and enabled by staff and volunteers as necessary, and have opportunities for social and educational development, including attending local colleges and visiting the nearby leisure centre, banks, pubs and restaurants. Residents also regularly attend the church of their choice. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 14 A team of up to thirty volunteers, working part time throughout the day with regular members of staff, endeavour to meet all residents identified individual and collective social care needs. They continue to support and enable residents to access a wide range of social and recreational activities. During this visit residents were able to talk about activities that they had completed that day that included shopping and having a coffee, working as a volunteer for a charity and cake baking. One resident spoke at length about the swimming that she liked to do and another talked about horse riding. Two residents live in the bungalows and are encouraged to be as independent as possible organising their own entertainment and spending time with their own friends and family. The Bradbury Activity and Resource service, which is located next door to Barclay House, provides residents with various opportunities for personal development, including independent living skills, numeracy and keep fit. The daily routines were seen to be flexible with interaction between staff and residents being productive and pleasant. All residents have single rooms that are seen very much as their private area where they can entertain friends, family and guests. The staff surveys received identified that the procedure for ‘service users finances’ has raised concerns around the promotion of residents rights and autonomy. Some residents have also felt the regular checking of their money was intrusive. Clearly it is important to safe guard residents but this must be balanced with residents wishes and their right to make decisions about their own money and this should be reflected in an individual approach supported by the organisations procedures. The registered manager confirmed that risk assessments are used for those residents that have declined the regualr money checks but they are in place for most residents. Residents are able to choose what they have for lunch and this is usually a sandwich or soup etc. The main meal which is normally the eveing meal was said to provide two choices. This was not the case on the day of this visit. Further choice and involvment of residents is recommended to promote a more inclusive approach to the provision of meals. For example they could be more involved in menu planning, shopping for the food and the preparation. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 15 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): 18, 19 and 20 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate arrangements are in place to meet the individual assessed emotional physical and medication needs of residents. Staff have formed positive relationships with residents and have a sound understanding of their individual care and support needs. EVIDENCE: All residents are given a copy of the ‘Charter of Service User Rights’. Discussion with staff during the assessment visit demonstrated that they worked in accordance with this charter appreciating and supporting residents rights. Residents are given privacy, respect and shown dignity and choice when meeting their personal healthcare needs. Staff were seen to be sensitive to residents privacy and dignity with support offered according to the individuals needs. Residents confirmed that they had showers and baths as they wished and felt that they had privacy when they needed it. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 16 The care documentation reviewed confirmed that the health care needs of residents are well attended to and reported on within individual health care plans. Each is registered with a local GP and have access to other health care professionals, including psychiatric nurses, consultants, physiotherapists, dentists and specialist ophthalmic services as required. One resident has increasing mental health needs and this is impacting on all residents in the home. The home have recognised these difficulties and is working with the community professionals to secure a suitable resolution. The registered manager must however liaise closely with them and the funding authority to ensure this matter is progressed. Detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. All staff responsible for administering medication have received training and are individually assessed and authorised to do so. Practice observed during the inspection process was seen to be good and safe. Medicine records reviewed were found to be accurate and clear. One resident administers his own medicines and staff are working with another to get her to a position where she can administer her own. Medicines are now stored in each residents room in a locked facility, enabling them to be stored and administered individually and directly, rather than from a central location. . Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 17 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): 22 and 23 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The open and inclusive atmosphere within the home enables residents, staff and visitors to feel able to express any concerns, confident that they will be listened to and acted upon. Residents are safeguarded from abuse through relevant staff training and robust policies and procedures. EVIDENCE: Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 18 All residents are provided with a copy of the ‘Service users’ Handbook’, which contains details of the home’s complaints procedure. This document is available in Braille or on audiotape. Residents are encouraged to raise their complaints and systems are in place to record these in a ‘complaints log’ along with the action taken and outcomes achieved. It was however noted that these complaints, that are often around living communally and refer to individuals, are displayed in the front entrance area and include records over the past two years. Whilst it is seen as good practice to record and respond to such complaints even if they are made informally, such information must be treated in a way that respects individual confidentiality as necessary. The registered manager agreed to store these records more securely. One written formal complaint has been received and is being responded to at an organisational level and relates to staff availability to escort residents to hospital at night. Regular residents meetings also provide an opportunity for concerns to be raised and discussed before they become complaints and more difficult to deal with. The home has detailed policies and procedures relating to adult protection, including a whistle blowing policy. The manager confirmed that she has attended recent training provided by East Sussex Social Services and had the new local policies and procedures in the home. She had a good understanding of Safeguarding issues and advised that staff receive training on an annual basis. A visiting professional confirmed that the home responds quickly and appropriately to any possible area of abuse. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 19 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): 24 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service is accessible, safe and clean and remains suitable for it’s stated purpose. Residents benefit from all necessary specialist equipment and pleasant accommodation that is comfortable, well maintained and decorated to a good standard. EVIDENCE: Barclay House is a purpose built home that provides an airy and spacious environment for residents. It includes ground floor accommodation with large bedrooms with en suite facilities and adapted shower and bathing facilities that can meet the needs of residents that have a physical disability and use a wheelchair. The communal rooms include a sitting room a large entrance area to the home and a combined dining kitchen area. There is however no separate quiet room in the home. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 20 Two residents are accommodated in two self-contained bungalows, within the grounds. These provide good accommodation for those residents able to live more independently but still need the supporting framework of residential care. The environment is well adapted with the use of bright colouring, textures and lighting to facilitate the orientation of people with sight impairment. The home also provides specialist equipment including a talking microwave, recording equipment - offering information about who is on duty and what is on the menu, liquid level indicators, talking scales and other household equipment has been fitted with tactile markings to enable use, e.g. raised markings on programme dial on washing machine. Bedrooms are decorated in accordance with residents own wishes and residents spoken to said how much they liked their rooms’ I have everything I need here’. The standard of decoration was good and it was noted that new carpet was being fitted in the corridor areas. The standard of cleanliness was also found to be of a good standard throughout the home. Barclay House DS0000032162.V369007.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): 32, 34 and 35 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by a team of competent and qualified staff although ongoing training is not well documented. The recruitment records did not demonstrate that best recruitment practice is being followed to ensure residents safety. EVIDENCE: At the time of this assessment visit two residents were living in the bungalows and seven residents were living in the care home. Although the residents in the bungalows have a lower personal and health care dependency the overall dependency of residents in the home has increased over the last year. Staff surveys commented on this increase particularly in relation to mental health needs. This along with a shortage of regular staff which has necessitated the use of agency carers has resulted in the believe by staff that residents are missing out on some activities planned. They stated; ‘The shifts are at times Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 22 too busy primarily due to the overriding needs of some residents over others. This is affecting the quality of the service provided’ ‘If there is enough staff on shift, everything is achievable. When there is a shortage of staff, usually activities have to be cancelled, leading to stress and frustration on every ones part’ ‘When short staffed we may have to cut back on outings’. The registered manager accepted that the dependency of residents has increased and that it had impacted on the staffing arrangements. She confirmed that the staffing provision is being reviewed currently and this will take into account not only the waking day staffing but the night time provision as well. Currently the home has a sleep-in night support worker. Recently this worker has been called upon to provide care and support and this has caused some concern from staff who feel that the current sleep in arrangement is not practical. The registered manager was also able to confirm that recruitment had taken place, which would reduce the use of agency staff. All feedback about the staff was positive residents and staff have a very good rapport and they like spending time with each other. Observation during the day verified that staff were available to support residents in a variety of ways. Records confirmed that new staff receive comprehensive induction and foundation training, the ‘Common Induction Standard’, which is compatible with Skills for Care. Staff routinely commence on their National Vocational Qualification (NVQ) as soon as possible after completion of their six monthly probationary period. The AQAA also confirmed that over 80 of staff at Barclay House are qualified to NVQ Level 2 or above. Contact with staff indicated a high satisfaction with the training provided at the home. Comments received included ‘SeeAbility offers intensive training’ ‘SeeAbilty are very willing to pay for any training’. Staff training records however seen as part of the inspection process were incomplete and did not evidence that staff had received even the basic core training required like safe moving and handling and fire training. The registered manager assured that staff had received the required training and acknowledged the poor record keeping, which would be reviewed as a priority and updated. The recruitment files pertaining to the three staff were reviewed as part of the inspection process. Although these included an application evidence of identification and the required Criminal Records Bureau and POVA checks on all staff. It was noted that two of the three files only contained one reference and none of them had a photograph of the employee or a copy of the terms and conditions of employment. These shortfalls were raised with the registered manager we agreed to follow up on these matters. Barclay House DS0000032162.V369007.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): People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a qualified and competent manager who is approachable and promotes the health, safety and welfare of residents. Systems are in place to take into account resident’s views on the service and its development. EVIDENCE: There is a new registered manager in post since the last inspection who has recently been registered by the Commission. She has an NVQ level 4 in care and is completing the Regsitered Managers Award. She is also an NVQ assessor and is undertaking a Leadership and Development Program. The registered manager has worked in the home for a number of years and Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 24 worked closely with the previuos manager to ensure a smooth transition of management responsibilties. The new manager is well thought of and all feedback regarding the homes management was positive. Comments received included; ‘There is an openness between staff and registered manager is approachable and amenable’ ‘the registered manager is very supportive and approachable’. There are various methods used to assess the quality of the service and promote continuous improvement including: annual satisfaction surveys with people who use the service and their relatives/friends. These are reported on and shared with residents. Regualr staff meetings are held and residents are also encouraged to share their views on a regular basis. Audits are completed and the AQAA is used as a quality monitoring tool. It was however noted that there is no system to evidence that the homes policies and procedures are reviewed on an annual basis. This was raised with the regsitered manager who agreed to action this matter. The registered manager confirmed that environmental risk assessments are completed and responded to. The organisation has recently carried out a full audit on health and safety and any issues raised have or are to be responded to shortly. The AQAA recorded that the necessary safety checks have been completed on equipment and services to the home. Barclay House DS0000032162.V369007.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 3 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 2 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 2 35 2 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 4 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22 Requirement Timescale for action 01/09/08 2 YA34 19 (1) 3 YA35 19 (5) The registered person shall establish a complaints procedure that deals with all complaints in an affective and responsible manner. The registered person must 01/09/08 ensure that the necessary checks and records are completed and held in respect of each employee. This must include two suitable references. That all staff are suitably trained 01/12/08 and qualified to work in the home and are provided with a rolling programme of suitable training. 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 YA6 Good Practice Recommendations That a system to demonstrate resident’s involvement in planning of individual care and agreement to any changes DS0000032162.V369007.R01.S.doc Version 5.2 Page 27 Barclay House 2 YA17 is devised. That the provision of food and meals in the home is reviewed with further emphasis on resident involvement. Barclay House DS0000032162.V369007.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone 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 Barclay House DS0000032162.V369007.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!