Inspection on 01/05/08 for Barkat

This inspection was carried out on 1st May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Barkat 03/05/07

Barkat 22/05/06

Barkat 11/01/06

Barkat 05/07/05

Barkat 19/01/05

Barkat 06/02/04

Barkat 19/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Barkat 254 Alcester Road Moseley Birmingham West Midlands B13 8EY Lead Inspector Jill Brown Unannounced Inspection 1st May 2008 08:55 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 Barkat DS0000016738.V363686.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. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barkat Address 254 Alcester Road Moseley Birmingham West Midlands B13 8EY 0121 449 0584 0121 449 2726 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) Ms Seemia Butt Ms Shahnaz Butt Ms Seemia Butt Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accommodate up to three people under 65 years of age for reasons of mental disorder. 3rd May 2007 Date of last inspection Brief Description of the Service: Barkat House is a large detached property situated on the main Alcester Road in Moseley. It is within easy walking distance of the main shopping area of Moseley where shops, restaurants, public houses and churches can be found and a larger shopping area can be reached by walking to Kings Heath. The home enjoys easy access to public transport routes leading to the city centre and beyond. Barkat House offers accommodation to currently 27 older people in single rooms on the ground and first floor and a number of these rooms have en suite facilities. There is a passenger lift between the ground and first floor. Communal areas are located on the ground floor. There is a large lounge to the front of the house, a smaller lounge to the rear. People that smoke use the small lounge. The home has a separate dining room. There are communal toilets and either assisted bathing or a shower facility based on both floors. The ground floor also houses the kitchen, office, laundry and large storage area. The home has a dedicated garden for the use of service users. The home has a small amount of parking at the front of the building. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1star. This means the people who use this service experience adequate quality outcomes. An unannounced Key inspection was undertaken on a day in May and lasted for about 9 and half hours. During this we looked at most of the standards. During the inspection three people’s needs were case tracked. This case tracking involved looking at all the records and information about them, looking at their medication and their rooms and observing their care. This assists us to make a judgement about the care given. The people accommodated at this home can have communication difficulties and a number had unsettled lives prior to admission. We received 3 comment cards from people living in the home. We spoke to two people living in the home. Other documentation in regards to the running of this home were examined and a tour of the building was undertaken. We also took into account information we had received from all sources about the home since the last key inspection. Services are required to complete an Annual Quality Assurance Assessment (AQAA) on a yearly basis; information from this was used in this report. We have received no complaints about this home since our last inspection. We were made aware of incident of a person being missing from the home. The acting manager has implemented systems to ensure that the late in returning of people who are in the community is noticed quickly. What the service does well: Detailed information is collected about the people that home intend to care for and this assists the staff to provide good care. This information included not only about a person’s health needs but also information about their ethnic background, religion and cultural needs. The home has staff from a range of ethnic backgrounds that speak a range of languages and this means that people have staff that they can talk to in their first language. There were good daily records, which showed where people had a change in their health and what action had been taken as a result. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 6 Residents had access to health services such as GP, district nurses, specialist nurses, opticians, dentists, chiropodist and so on as needed. People have been asked about their views on the service provided and some changes are being made. People living in the home are welcome to have visitors and there are no undue restrictions on people’s movements within the home. Staff have received training on safeguarding and the home responds well to any safeguarding issue that is raised. There is good support to people living in the home to manage their money in way that suit them. The home ensures that maintenance and inspection of building services such as electrical wiring, gas and fire safety are undertaken routinely. This ensures the safety of residents. What has improved since the last inspection? What they could do better: The information collected prior to a person being admitted does not always result in a judgement about whether the person meets the categories of their registration. Whilst this has not meant that the have not cared for the person it could lead to a person’s needs not being met. The home has information available about the home but this needs to be updated and developed to ensure that people admitted and their representatives can use it. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 7 Care plans need to be shared with the person and their content reviewed monthly to ensure that the care given remains appropriate. Care plans need to detail what actions the home are taking to ensure that people’s ethnic religious and cultural needs are met. Relevant risk assessments need to be completed in more detail to ensure that the difficulty causing the risk can be minimised where possible. Medication brought into the home needed to have more robust checks and people needed to be assessed for their ability to self administer medication where they request this. People living in the home wanted more outside and varied activities than on offer. Whilst the menus have been redrafted to meet the expectations of the people living in the home these had not been implemented. There are no systems in place to help people to have a healthy eating plan. The garden needs to be improved and furniture provided so people can use it when the weather is appropriate. Further attention and staffing is needed to mange the cleaning needs of the home. The staffing provided can only deal with the immediate cleaning needs and deep cleaning is needed more often to ensure that the home is hygienic and odours in some bedrooms are lessened. Laundry processes must be improved to ensure that soiled linen is carried in closed containers. Heating must be available to residents that use their rooms during the day. The registered manager who is also an owner has been on maternity leave and may be not returning as the manager. There is an acting manager in place but more permanent arrangements must be provided so there is a full time Registered Manager available. 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. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 8 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 Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4 & 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is information available for people that live in the home but this is not available in a way that is easily accessible to them. This means that people may not always know their rights. Although the home collects good information this does not always ensure that the home only admits people that they can care for. EVIDENCE: There was a statement of purpose available for people living at the home to refer to. However this had not been updated to reflect the changes in the service provided. People admitted to the home have a contract for their stay, which includes the fees that they pay per week. There was some information in some of the bedrooms of some peoples’ rooms giving information about their stay but not in all bedrooms. This information was not translated into the first languages of Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 10 people living in the home. People were not sure that they received a contract or information before choosing this home. We looked at the way three people were admitted to this home. We found that two people had health conditions, which meant that the home was not registered to care for. These conditions of registration are currently under review. One person’s health condition is unlikely to part of their new condition of registration. This means that the home does not have the specialist skills to meet the needs of these people. However in one situation the home had detailed advice from specialists and was working to these guidelines with good effect. People were sometimes accepted for admission in emergency situations when their circumstances were unsettled but the home managed these admissions well. A resident spent a day and night at the home before deciding to remain at the home. Another person had a short stay before deciding to stay. The home collected what in formation was available and added to this information as they acquired it. As well as people’s health and social needs they also collect information their lives and their social religious and cultural needs. The home has staff from arrange of ethnic backgrounds and all people at the home had staff that could communicate with them. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. People living in this home have a plan of care that instructs staff how to deliver their care. People have their personal and healthcare needs met and this helps to ensure that they remain well. Some improvements were needed in medication administration, recording and risk assessments to ensure that people’s rights were maintained and risks lessened. EVIDENCE: The home had reorganised care plans since the last inspection. These covered the main areas of care and support needed for the person. Staff had access to the care plans at all times and this assisted staff to give appropriate care. Some reorganisation of instructions to staff in the care plan would assist in Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 12 delivering care such as keeping how to deliver the personal hygiene together. Care plans were reviewed with social workers but were not reviewed monthly to see if the plan still managed the care needed. Some people’ thought they had seen their care plan others thought that they hadn’t. The people at the home are registered with one GP practice that had changed recently. People thought that they had access to doctors and other health professionals when needed. The home records showed that new admissions to the home had consultations with opticians, chiropodist GPs and so on when needed. A health professional said that the service to people in the home had improved and this was because of the acting manager. There had been an improvement in the communication with health professionals and more interest shown in the outcome of consultations. The health professional said that people’s personal hygiene needs were more consistently being met. Although there was information collected about peoples religious and ethnic background this did not result in recording in the care plan to ensure the care. The home however did ensure that residents had access to appropriate food and religious observances where necessary. This relies however on all staff being aware of these for the range of religions catered for in the home. Risk assessments for falling, choking and medication misuse were completed for each person regardless whether this had been an issue for them. Some other risk assessments were completed in a standard way and not personalised to the risk for each resident. One person had very detailed risk assessments to manage their behaviour. A number of people have been assessed for and have personal aids such as hoists, special mattresses to prevent pressure areas and walking aids. People that have en suite facilities have grab rails or raised toilet seats if needed. There were good daily records kept with entries being found recorded twice daily and issues about changes in people’s health and care needs being recorded and followed up. The supplier of people’s’ medication had changed and a copy of the prescription was not being seen before it was dispensed. This means that a valuable check that medication is correct is lost. The storage of medication was good with medication being held securely. No person living in the home was self-medicating at the time of this visit, a survey undertaken by the home found that a number of people wished to self medicate. The home had yet to undertake risk assessments of the person’s ability to do this and where they had concerns consult the health professionals involved with the person. The medication administration records checked found there were no gaps in recording when medication given or not given however there were a couple of errors with the amount of medication left. The supply of some medication was Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 13 getting very low, on two occasions the amount of medication was not written on the MAR and one medication was not recorded as being discontinued. The home retains information about medication so that staff can read about them. The staff member spoken to had some knowledge about the medications and their use. Although audits of medication were being done it was difficult for the home to identify specific members of staff that may have difficulty with administering medication. People living in the home stated ‘ usually get the support I need’ ‘ the staff are nice.’ People were observed to be treated well however a couple of entries on daily records were not written in a way to show respect to people or understanding of their health conditions. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 14 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 adequate . This judgement has been made using available evidence including a visit to this service. The activities available are not varied or often enough to meet people living in the home’s expectations or needs. People have access to visitors and have no undue restrictions and this enhances their life. Although people living in the home have a choice of food this does not always meet their expectations or maintain a healthy lifestyle. EVIDENCE: Recording of activities that people living in the home had been involved in was not good. It was found that care plans did record what people were interested in past hobbies and work and lifestyle but these were not always used as means of ensuring people had social activities that were meaningful to them. The home had surveyed their views and the people living in the home thought that they wanted to go out of the home more, one person said they were happy as long as they could go to the local pub, others thought the garden needed improving so they could use it one person wanted it to have flowers Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 15 and a number thought that the exercise and mobility person should come more often. One person stated that they had made friends at the home and enjoyed watching the Asian films on the television. The large lounge has two television areas one side showing Asian programmes and the other English. There is a snooker table for those who wish to play. We received one questionnaire from a relative. It said ‘ I believe that the prime requirement is patience under difficult circumstances and staff at Barkat demonstrate this to a remarkable degree.’ Those people living in the home that completed surveys thought that they could have people to visit when they wanted. There were no undue restrictions on people living in the home. The front door was locked to protect a number of people but was opened on request for those able to access the community safely. A number of people spent time in their own bedrooms during the inspection day. There was not a lot of food in the home on the day of inspection however it was the day for food to be brought in. There was enough food on the premises for two to three days. There was not a large amount of variety in the food that was left. The manager had devised new menus but these had yet to be implemented. We found no strategies to ensure that people living at the home had healthy food options. People that have Asian food have this supplied from a local Asian day centre and there was no menu for this available this needs to be available. People thought the menu was to change and that they had an input into this change. One person stated that if they didn’t like the options they were offered alternatives. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that their views about the service provided will be asked for but this does not always result in quick action to address shortfalls. People in this have the benefit of staff that have been trained in safeguarding and management that will respond to any shortfalls found. EVIDENCE: We have received no complaints about the running of this home. The Annual Quality Assurance Assessment (AQAA) stated that the home have received no complaints. An in depth survey has been completed with each person living in the home about their thoughts about the service provided. These surveys suggest that people are not sure how to complain and this must be addressed as soon as possible and methods devised to ensure that people could access this information in the most appropriate format for them. However people are becoming more involved in shaping the service. People stated that staff listened to them. There has been an incident where a person’s safety has been compromised due to an inadequate system of monitoring people who are not in the home and lack of monitoring of their proposed return. This led to involvement of the police. The acting manager took the matter seriously has developed systems to ensure the safety of future people. There have been no other incidents of Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 17 concern. The home has people that can show challenging behaviour but have successfully shown that this has been managed. The Annual Quality Assurance Assessment stated that over 50 of care staff have a National Vocational Qualification level 2 in care and have attended courses on the Protection of Vulnerable adults course. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the environment is improving more attention is needed to deep cleaning and the access to garden facilities to ensure that people have a comfortable and pleasant place to live. EVIDENCE: Since the last inspection the environment has continued to improve and the people living in the home commented on the improvements in the home’s survey. The windows in the home have all been replaced the front and side drives have been resurfaced. The dining area has new flooring and new furniture. One of the corridors has had new flooring. A number of beds have been replaced and there has been some new linen and pillows. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 19 There has been alteration to the layout of the main lounge to accommodate people that wish to enjoy Asian programmes on the television. There is a ramp access to the front door and the back garden is accessible for wheelchairs. There is a lift to the first floor and where there are changes in floor levels there are ramps to accommodate this. All the bedrooms in the home are single with a number having en suite facilities. Bedrooms vary in size but people’s needs can be met in theses rooms. There is an assisted bathroom and shower facility that meets the needs of the people in the home. A further bathroom and shower room are available for those residents that are independently able to care. There remain a number of small repairs and redecoration items in bedrooms. One bedroom needed to be redecorated and investigation of the condition of the wall behind lifting wall paper. One toilet needed some work to ensure that the light switch was appropriately placed so that people using it could find it before shutting the door. As previously stated the garden needed to be landscaped and appropriate furniture to be available for people to be able enjoy when the weather allows. A number of people commented that the bedrooms were cold during the day we were told that the boiler for the home was in the kitchen and was adjusted during the day. The home has been granted planning permission for a ventilation flue from the kitchen and the boiler will then be kept at a static temperature. The home was not cold in area at the time of the inspection. Although there is a cleaner employed by the home there are not enough cleaning hours to ensure that deep cleaning is undertaken in bedrooms and the kitchen. We found that easy chairs in the bedroom had not been cleaned, ventilation fans were dirty, odours were evident in some rooms and the kitchen needed a deep clean. A number of people living in this home have needs that require deep cleaning of bedrooms more often. Whilst it had been decided that each bedroom has its own linen as a measure to maintain good infection control further measures needed to be in place to ensure soiled linen is only transferred through the home in closed containers. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst there are enough staff to deliver care to people living in the home further staffing was needed to ensure that the environment was clean at all times. Staff were recruited appropriately trained and received updates on training; this ensures that people living at the home are in safe hands. EVIDENCE: There have been no changes to the staff group since the acting manager has been in place. There was an advert for a senior carer and the home were hoping that may be able to employ a male carer to allow the large number of male living in the home to have the opportunity for this contact. During the week there were 2 carers a senior carer, a cook and a housekeeper on duty. At the weekend this changes to 4 carers and a senior in the morning and 2 carers and a senior carer on the afternoon and evening with housekeeper support. There is no cook support at the weekends and the rota does not show which staff are undertaking this role. The manager and deputy manager hours are in addition to this. The rotas that were supplied at the time Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 21 of the inspection showed this. The people living in the home thought that they received care when they needed it. We looked at the employment records for three staff and found that there pre employment checks from Criminal Records Bureau, Protection of Vulnerable Adults lists and references had been undertaken. Previous records of training were available for inspection. The Annual Quality Assurance Assessment stated that 7 of the 13 care staff have completed their NVQ 2 and all seniors have either completed or are signed up to complete a NVQ3. The care staff have completed updates on mandatory training including Health and safety, food and hygiene, Protection of Vulnerable adults, First aid, infection control moving and handling and a ½ day awareness course on dementia care has been planned. They have completed a course with west midlands fire service earlier in the year. The acting manager was doing some supervision of staff but this had yet to be in a regular pattern. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. People living in this home can be assured that their financial interests and safety are safeguarded. People’s views about their care is being taken note of and improvements are being made as a result of this. EVIDENCE: The registered manager of the home who is also one of the owners was on maternity leave and we have not been informed of when she intends to return. There was in place an acting manager that had been employed via a recruitment agency and details of that recruitment were not seen on the day of the inspection. We understand from the Registered Manager’s representative Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 23 that Registered Manager may not be returning in this role and we must be formally informed of the permanent arrangements for registered manager of the home. We are aware that the acting manager has worked for number of years as the deputy manager in a care home. In March there was a survey of the views of all the people who live in the home about the service they received. Some work has been done in changing menus as a number of people requested. However further work was needed on improving the gardens and the range of activities to ensure that people’s views was adequately listened to. The AQAA was completed in a limited way and needs to developed so it can be used as part of the homes auditing of the quality of the service they are providing. We looked at the financial arrangements either in part or wholly for 5 people and found the following. Money is managed in different ways to suit the needs and wishes of the people living in the home. A number of people are enabled to have their personal allowance on a weekly or daily basis or the home manages their money or relatives do. There have been difficulties in ensuring that people can have access to bank accounts because of their previous unsettled lifestyles and lack of proof of identity. This has meant some complex systems to ensure that a person’s whole finances can be managed. Generally money matched the records that the home kept. Money was held securely at the home. We found that the maintenance and inspection of services to the home such as electrical hard wiring, Gas safety, lifting equipment, and fire safety equipment were serviced and maintained appropriately. There has not been a fire drill since September 2007. Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 24 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 2 3 3 2 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation CSA 2000 Requirement People must not be admitted to the home if their needs fall outside the homes categories of registration. This is to ensure that people have their needs met. There must be a timely reordering of medication to ensure that people are not left without medication. The new menus must be implemented and include a healthy option for the main meals of the day. This is to promote the option of healthy eating for people living in the home. 4 OP25 23(2)(p) Bedrooms in the home must be 22/06/08 kept warm enough for those people living in the home to use them during the day if they wish. Measures must be taken to 22/06/08 improve the infection control in the home including: Ensuring an effective process for containing and handling infected Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 26 Timescale for action 22/06/08 2 OP9 13(2) 22/06/08 3. OP15 12(1)(a), (3) 30/06/08 5 OP26 13(3) linen is written and adhered to. Deep cleaning of bedrooms and the kitchen on a regular and routine basis. 6. OP27 18(1)(a) Outstanding since 31/07/07 Further cleaning hours must be added to ensure good infection control and to make the home comfortable for residents. (Outstanding since 30/11/06 and 31/07/07) Details of the arrangements for the provision of a registered manager must be sent to the commission. 30/06/08 7. OP31 38 22/06/08 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 OP1 Good Practice Recommendations the statement of purpose and its service user guide should be reviewed to ensure that residents and their representatives have appropriate information in an appropriate format to determine whether the home can meet their needs. A copy of the revised documents should be sent to the Commission. 2 OP4 It is recommended that the home confirm in writing to new residents or their representative that the home is able to meet the resident’s needs a copy of this letter should be retained. (outstanding since May 2007) Care plans should be written with, shared with and signed by the resident wherever possible and dated. 3 OP7 Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 27 Care plans should be reviewed monthly to ensure the care given remains appropriate. Care plans should have instructions about how cultural religious and ethnic needs are to be met. 4 5 6 OP8 OP8 OP9 Risk assessments must in all cases have details about what is causing the risk and actions to minimise these. It is recommended that the home purchase seated scales. Outstanding since May 2007 A copy of prescriptions must be obtained to ensure that the dispensed medication in correct. Those people wishing to self medicate must have a risk assessment to determine whether this can be enabled safely. Records must be appropriately kept that reflect the dignity of the person. Further activities must be arranged to meet the needs of the people living in the home. The garden must be improved to ensure that residents can spend time in it comfortably. A bedroom should be redecorated and any damp patches repaired. The home must develop a range of audits of its service with is surveys of the people that live in service to produce an annual action plan. 7 8 9 OP10 OP12 OP19 10 OP33 Barkat DS0000016738.V363686.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Barkat DS0000016738.V363686.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. 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