Inspection on 15/11/06 for Barford Court

This inspection was carried out on 15th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Barford Court 12/11/08

Barford Court 10/11/05

Barford Court 02/06/05

Barford Court 08/02/05

Barford Court 01/09/04

Barford Court 25/11/03

Barford Court 06/06/03

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

CARE HOMES FOR OLDER PEOPLE Barford Court 157 Kingsway Hove East Sussex BN3 4GR Lead Inspector Jennie Williams Unannounced Inspection 15th November 2006 10:00 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 Barford Court DS0000013959.V309746.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. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barford Court Address 157 Kingsway Hove East Sussex BN3 4GR 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) 01273 777736 01273 777633 barford@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution Mrs Susan Hale Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That service users accommodated must be aged sixty-five (65) years or over on admission. That the home may admit three (3) named service users who are under the age of sixty-five (65) years. That the maximum of twenty-five (25) service users accommodated will be in receipt of personal care only. That a maximum of fifteen (15) service users accommodated will be in receipt of nursing care. That the maximum number of service users to be accommodated is forty (40). 10th November 2005 Date of last inspection Brief Description of the Service: Barford Court is a care home registered to provide accommodation for forty (40) residents. The home provides nursing care for a maximum of fifteen (15) residents and personal care to a maximum of twenty-five (25) residents. The home is part of the Royal Masonic Benevolent Institution (RMBI). The home is located in Hove and is within walking distance of the seafront and local amenities. The home is a large building and is separated into four units. Car parking is available at the home. There is nearby access to public transport. Residents’ rooms are located over two floors. Passenger shaft lifts are present within the home to assist residents to access all areas. All rooms are for single occupancy and provided with en suite facilities. There are suitable bathing and toilet facilities located throughout the home to meet the needs of the residents. There is a large indoor garden/communal sitting area and eight day/quiet rooms throughout the home for residents/relatives to use. There are easily accessible, well maintained gardens to the front and rear of the home. Weekly fees range from £531 to £755 per week. There are additional fees; hairdressing (£6.50 to £27.50), chiropody (£9) and newspapers/magazines. This information was provided to the CSCI on the 30 October 2006. Prospective residents know about the service through social service referrals, word of mouth and living in the area. A copy of the most recent CSCI inspection report is available at the home. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Barford Court will be referred to as ‘residents’. This unannounced key inspection took place over five and a half hours on the 15 November 2006 and five hours on the 17 November 2006. Due to the size of the home, the CSCI Pharmacist Inspector visited the home for three hours on the first day of the inspection to assess medication procedures. These findings are incorporated into this inspection report. Eleven (11) residents, of both genders, were spoken with during the inspection. One resident did not wish to be involved in the inspection process and this was respected. Fifteen resident surveys were given to residents at inspection, of which seven were returned. Four care plans were viewed. One care plan was looked at in detail with the resident involved and with their permission. Specific areas of care were looked at in two other care plans. The Registered Manager, deputy manager and five staff members, of various positions, were spoken with during the inspection. The Pharmacist Inspector spoke with four care staff. Ten staff surveys were left at the home of which one was returned. Four staff files were inspected. Ten relative/visitors comment cards were sent to the home prior to inspection. One of these was returned. A GP comment card was sent out, which was returned. A pre-inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Fire records and accident records were inspected. The quality assurance system was discussed and complaint records were inspected. Previous requirements and recommendations at the home were assessed to ensure compliance. The staff rota and menus were viewed. The Inspector ate lunch with the residents. Apart from fire records, no other health and safety records were viewed as this information has been provided in the pre-inspection questionnaire. Some policies and procedures were viewed. There were forty (40) residents residing at the home on the day of the inspection. Fifteen (15) in receipt of nursing care and twenty-five (25) in receipt of personal care only. What the service does well: Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 6 Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. All prospective residents are assessed prior to admission to ensure all needs can be met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will suit their needs. Residents felt that their privacy and dignity are respected. Visitors are welcomed at the home and residents may receive visitors in private. Residents confirmed that their lifestyle within the home is their own choice. Activities are regularly provided if residents choose to be involved. Residents were complimentary about the provision of food at the home. Residents feel comfortable and know how to make a complaint and feel that they will be listened to. Residents are happy with their individual rooms and are able to personalise them. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Residents and staff benefit from supportive management within the home. Residents finances are safeguarded with the recording systems in place. The health and safety of staff and residents are promoted and protected so far as is reasonably practicable. 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. Barford Court DS0000013959.V309746.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 Barford Court DS0000013959.V309746.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission assessment process ensures that only residents whose needs can be met are admitted and prospective residents are provided with an opportunity to visit the home to ensure it meets their expectations. Intermediate care is not provided at the home. EVIDENCE: All prospective residents are assessed prior to being admitted into the home. Pre admission assessments viewed for recently admitted residents provided good information on the needs of the individual. The Registered Manager or a Registered Nurse will undertake the assessments of all prospective residents. Relatives are involved in this process wherever possible and information is obtained from social services and health professionals wherever applicable. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 9 Residents/relatives are provided with an opportunity to visit the home prior to admission. It was confirmed that the first month of admission is a trial period. Of the residents that were asked, all confirmed that they or a relative had visited the home prior to moving in. The Registered Manager confirmed that there was no one residing at the home from any minor ethnic community or social/cultural or religious groups with any specific needs or preferences. The home does not have dedicated accommodation to provide intermediate care. Respite care is provided if there is a spare place available. The home does not take emergency admissions. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. The service meets the healthcare needs of residents. EVIDENCE: Care plans provide clear guidance for staff on the assessed needs of the individual. A new care plan format has been implemented since the last inspection. With the permission of a resident, the Inspector went through their care plan with them and this individual confirmed that the information within the care plan was accurate. The GP comment cards shows that staff demonstrate a clear understanding of the care needs of residents and any specialist advice given is incorporated into the residents care plan. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 11 There was no evidence that care plans were being reviewed with the resident/relative to reflect personal choice and preference. Some residents spoken with stated that staff don’t discuss their care plans with them. Turning charts in use were not being completed accurately. (Turning charts used for people who have limited movement and are at risk of developing pressure areas.) Some demonstrated that residents had been left lying in the same position for a whole day at a time, increasing the risk of pressure areas developing. A Registered Nurse confirmed that this care had been provided, however staff were not accurately recording the care provided. The Registered Manager is aware of this shortfall and is taking action to address this. Pressure relieving equipment is available at the home. Specialist advice is sought when the needs arise. The home arranged for a tissue viability nurse to undertake an audit on beds and mattresses provided at the home. The Registered Manager confirmed that this was a beneficial activity and new electric profile beds have been provided for all residents. New dynamic overlay mattresses have also been provided. Some resident observed to be wearing glasses confirmed that eye checks are arranged when they need. A resident confirmed that they have hearing checks and dental checks when they chose. The GP comment card demonstrates that management/staff take appropriate decisions when they can no longer manage the care needs of the residents. Care notes written on some individuals do not provide sufficient information to monitor their health. Writing ‘no problems’ does not provide suitable information. The Pharmacist Inspector talked to four members of staff at varying level of seniority. A few residents self medicate their own medicines on a risk assessment. There is little detail regarding exactly what aspects are managed by the home staff and by the resident around self-administration. There was evidence of diversity around medicines as times of medicine administration for a couple of residents had been changed to suit them. Concerns were identified around controlled drugs. [CD] There was an entry in the CD register stating a quantity of medicine had been destroyed in June 2006. This medicine was in the CD cupboard. Corrective action was taken immediately. This medicine could have been misused. One resident selfmedicates a CD. A supply of this was seen in the CD cupboard but no reference was seen in the CD register. The CD register is a record of the controlled drugs status in the home. It must be accurate. The GP prescription orders are done for three months at a time, two months being kept safely in the home until needed. There is a potential risk of misuse of these printed prescriptions. There is also the matter of medicine prescription available for medicines not required. An example of excess supply for an analgesic was seen due to this system. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 12 There is planned program for external medicines training and there is a good appraisal system for competence assessment. A few improvement points identified are; to have consent from residents for managing there medicines if not self-medicating, to have evidence for when giving a months supply of medicines to self-medicating residents and to review the medicines policies. It is noted that the member of staff who did not follow the home’s policy is being dealt with in the appropriate manner. All residents spoken with confirmed that they felt that their privacy and dignity are respected. Staff are sensitive to residents who may be in a relationship and ensure that privacy is respected. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: There is an activities person employed at the home, who is currently on leave from the home. An additional staff member is employed to ensure that regular activities are still being provided to residents. Residents spoken with felt that there were sufficient activities provided at the home, should they choose to be involved. The home has a bus on site that is used for outings. There are facilities for two wheelchairs to be able to be clamped securely into the bus. On the day of the inspection, there were residents from another RMBI home visiting Barford Court. It was confirmed that residents from each of the RMBI homes that are within travelling distance, will visit other RMBI homes. An outside entertainer had been arranged for all the residents. Residents were observed to be enjoying this activity. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 14 Visitors are welcomed at the home. There is a visitor’s book at the entrance to the home that all people must sign when entering and leaving the building. Residents are able to receive visitors in private, should they wish. The relative/visitors comment card showed that they are welcomed in the home at any time and are able to visit their friend/relative in private. Residents confirmed that routines of daily living were flexible and their own choice. Residents were observed to move freely within the home. The care plans provide a quick page summary of residents’ preferences during the day. Examples are: preferred bedtime for going to bed and getting up and whether they like a drink at these times, bathing preferences. etc. Residents were complimentary about the food provided at the home. Comments ranged from good to excellent and residents confirmed that there is a choice available. The Inspector ate a tasty roast meal with the residents. Residents were observed to be enjoying their meals and staff were observed to be nearby and offering discreet assistance when required. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Protection of Vulnerable Adults procedures ensure residents are safeguarded. EVIDENCE: The home has a suitable complaints procedure in place and records show that complaints are dealt with in a non-biased manner. Records of complaints are kept within individual resident files. It has been recommended to the manager that she maintain a central record of complaints for easy access to this information. Of the residents that were asked, all confirmed that they feel comfortable to make a complaint. There has been two complaints made to the home since the last inspection. These were investigated by the home and were found to be substantiated and appropriate action was taken to resolve these. No complaints have been made directly with the CSCI. There is a Safeguarding adult’s policy in place and staff receive Protection of Vulnerable Adults (POVA) training. The staff comment card received showed that they are aware of adult protection procedures. There has been two POVA alerts made since the last inspection. Records demonstrated that the home Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 16 followed correct procedures and advice was sought from Social Services who are the lead authority. Social services were happy for the home to deal with these allegations internally, which resulted in disciplinary action being taken. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: The home is located in a residential area of Hove and is within walking distance to the seafront and local amenities. There is also a small shop opened at the home one morning a week that sells sweets and toiletries etc. This enables residents to purchase items themselves if they are unable to access local shops. The home is spread over a large area and rooms are located over two floors. There is a passenger shaft lift available to enable residents to access all areas of the home. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 18 There are well-maintained gardens to the front and rear of the home that residents have access to. There is an enclosed fishpond within the grounds. There is suitable communal space for residents living at the home. There are small sitting areas throughout the home and a large indoor garden/communal area that provides residents with a relaxing atmosphere. All rooms are for single occupancy. Rooms that were viewed were of a good standard and were observed to be personalised to reflect the individuals’ choice and personality. Of the residents that were asked, all confirmed that they were happy with their individual rooms. The pre-inspection questionnaire demonstrated that there is ongoing work to maintain a good standard throughout the home. Bedrooms are being redecorated and carpeted as they become vacant as part of the ongoing upgrading of the home. There is a small kitchen area located on each unit that is used to make refreshments and serve meals that have been prepared by the main kitchen. All four kitchens on the units have been refurbished. This work was being completed on the day of the inspection. The home was clean and free from offensive odours on the day of the inspection. All residents surveys received showed that they always found the home fresh and clean. There are now sluice facilities provided on every unit. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty and are safeguarded by the recruitment procedures in place. EVIDENCE: Residents were very complimentary about the staff working at the home. Comments ranged from ‘very good’ to ‘marvellous’ and all confirmed that staff encourage independence. Most residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. Five resident surveys demonstrated that staff are usually available when needed. Two stated staff are always available. The shift times for carers have changed to ensure that there are sufficient numbers of staff at peak hours. The Registered Manager confirmed there is always a registered nurse on duty along with seven carers in the morning, six carers in the afternoons and four carers at night. There are currently carer vacancies to cover 76 hours a week. The home currently has to use agency staff. The home ensures that the agency provides continuity of staff wherever possible. Staff files inspected demonstrated that the home follows a robust recruitment. Application forms are completed and at least two references are obtained for Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 20 all prospective staff members. A POVA First check is undertaken and a Criminal Record Bureau (CRB) is obtained. Staff that commence work with only a POVA check in place is supervised whilst working until confirmation of a CRB has been received. The RMBI human resources view individual’s health questionnaires and will provide written confirmation to the home if that individual is suitable to commence employment. The home has systems in place to ensure that all registered nurses Professional Identification Number (PIN) remain valid and are registered with the Nursing and Midwifery Council (NMC). There are 24 care staff employed at the home, of which 14 have obtained National Vocation Qualification (NVQ) level 2 or above. This meets the recommended ratio of 50 of care staff with NVQ qualification. Staff spoken with confirmed that they are kept up to date with all mandatory training and stated that there was enough training opportunities provided. Staff confirmed that some recent training undertaken were: leg ulcers, POVA, documentation and fire training. Diversity training was being provided on the day of the inspection. The home has information available about the new Common Induction Standards that have been newly implemented and the Registered Manager confirmed that training has been undertaken on the new process. The care staff comment card identified that they received induction training when they began working for the home. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: The registered manager was approved registration with CSCI in September 2005 and has the relevant skills and experience to manage the home. She has had over 20 years of care experience in a variety of roles and settings. She has current registration with the Nursing and Midwifery Council. A deputy manager has been employed at the home to provide support to the Registered Manager. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 22 The Registered Manager confirmed that the head office of the RMBI is in the process of redeveloping the quality assurance and quality monitoring system to assist in obtaining the information that will be needed in the changes to the CSCI inspection process. The home has a suggestion box that provides an opportunity for all involved with the home to make any complaints/suggestions/comments anonymously. There are relative comment cards near the entrance of the home for people to take at any time. The Registered Manager confirmed that the previous quality assurance process did not have any specific process in place for obtaining information from visiting health professionals. The home is not an appointee for any residents. Personal allowance is held for individuals securely at the home if residents choose to use this service. Residents whose personal allowance is held at the home are aware that their money is only accessible during office hours. There is a no interest bearing account for residents to ensure that excess money is not held at the home. There are clear records being maintained of residents’ personal allowance. Records are maintained on a password-protected computer. There are receipts kept of financial records. The Registered Manager and staff spoken with all confirmed that all staff are kept up to date with mandatory training. The most recent fire drill was in October 2006. The pre-inspection questionnaire demonstrates that the last fire officer visit was in September 2006 and there were no requirements made at this visit. The Registered Manager informed the Inspector that since the last inspection one room has had overhead hoist tracking installed. This assists staff in easier manual handling techniques. The Registered Manager is hoping to obtain funding to do an additional three rooms. No health and safety records were inspected on this occasion as this information has been provided in the pre-inspection questionnaire. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X X X X 3 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 X X 3 Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 24 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. 2. Standard OP7 OP9 Regulation 15 13.2 Requirement That care plans be reviewed with the service user or representative. Medication must not be entered out of the Controlled Drugs register until it leaves the home. The balance in the Controlled Drugs register must reflect the balance in the Controlled Drugs cupboard at all times in order that any misappropriation of medication can be detected. The receipt and disposal of Controlled Drugs, including Temazepam, must be recorded in the Controlled Drugs register. This applies to all controlled drugs kept in the cupboard. Timescale for action 15/01/07 15/01/07 3. OP9 13.2 15/01/07 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 Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 25 1. 2. OP9 OP9 To have written documentation to clarify the exact level of self-administration. To manage the ordering of further supplies of medicines according to needs despite having a prescription for the medicine. Barford Court DS0000013959.V309746.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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