Inspection on 03/10/05 for Barlavington Manor

This inspection was carried out on 3rd October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Barlavington Manor 25/05/06

Barlavington Manor 05/05/05

Barlavington Manor 25/11/04

Barlavington Manor 04/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Barlavington Manor Burton Park Road Heath End, Petworth West Sussex GU28 0JS Lead Inspector Sheila Gawley Announced Monday 3 October 2005, 8:00am rd 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 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. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Barlavington Manor Address Burton Park Road, Heath End, Petworth, West Sussex, GU28 0JS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01798 343309 Realmpark Health Care (Petworth) Limited Ms Amanda Therese Ashton CRH 64 Category(ies) of Care Home Only (PC) 64 registration, with number of places Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 21 persons in the category MD(E) to be accomodated 2. A maximum of 21 persons in the DE(E) to be accomodated 3. A total of 64 ser may be accomodated at any time. Date of last inspection 05/05/05 Brief Description of the Service: Barlavington Manor is a Care Home, standing in extensive, well cared for grounds, in a rural area near Petworth. It is owned by Realmpark Healthcare (Petworth) Limited (Organisation). The main house is for forty-three service users in the category of Older People. In addition to this there is separate extended accommodation for service users with dementia. This unit provides en-suite accommodation for twenty-one service users making a total of sixtyfour service users. Separate entrances,reception offices, car parking and communal areas are provided for each category of registration with a security system for the service users with dementia. The responsible person on behalf of Realmpark Health Care (Petworth) Ltd is Mr Lawrence Harvey and the registered Manager is Ms Amanda Ashton. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced inspection was carried out on 03/10/05. The premises were inspected, residents, visitors and staff spoke to and all expressed that a high standard of care was offered. The premises remain in good decorative order. The overall standard of care observed was good and there was evidence that the needs and opinions of residents are taken into consideration. Residents able to express an opinion mainly felt they could complain. The level of staffing in the dementia unit remains a concern, as that observed on this occasion was less that that provided elsewhere in the home. The registered manager, and senior members of staff facilitated the inspection. The inspection report will be informed by the observations at inspection, residents, staff and relative’s comments and the comment card and letters received at the commission. What the service does well: 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. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 No resident moves into the home without having had his/her needs assessed and been assured that these will be met. EVIDENCE: Care plans inspected today had evidence of pre assessment. Discussion was held with the manager on improving the documentation to state explicitly where the assessment has taken place. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,11 Residents make decisions about their lives with assistance as needed. Residents, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Residents spoken to today all expressed a satisfaction with the way they are cared for and many stressed that the have a great deal of choice in how they run their lives. Policies and procedures for the receipt, storage, administration and disposal of drugs were available for inspection. The inspection of the drugs trolley and the medicine administration charts demonstrated that these were being adhered to. MAR charts were up to date with drugs prescribed correctly entered on the charts with the exception of an entry which stated that the resident was having a tablet and a liquid form had been supplied. The deputy manager stated that in future should the pharmacy make this alteration she will request a further label to correctly show on the MAR chart the medicine being administered. Residents are risk assessed regarding self-medicating and two do so at present one has a lockable space for medicine and the other has not, the provision of this was discussed with the manager. Self-medication is Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 9 recorded on the medicine administration chart and care plans and monitored regularly. Boots the chemist provide pharmacy support and staff administering medicines have received training. There are not sample signatures and the deputy manager stated that she will put this in place. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 Residents find the lifestyle experienced in the main part of the home matches expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. This is not as evident in the dementia unit. Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The lifestyle and interactions between staff and residents in the main part of the home was lively and stimulating and residents confirmed that they were lee happy with the activities. These activities are posted on the notice board. The activities coordinator and staff were spoken and she confirmed that the majority of residents enjoyed these activities. The manager stated that since the last inspection an activities coordinator has been employed for three afternoons a week in the dementia unit. There were not any stimulating or therapeutic interventions observed in this unit on the morning of the inspection, nor was there any supervision of the residents and this was discussed with the unit manager and the registered manager. Two staff were on tea break and the remaining two staff on the floor were again observed doing kitchen duties with no staff in attendance in the lounge with the residents. This unit does not have comparative housekeeping support as the main part of the home a situation that has not improved since the last inspection. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 11 The meal seen prepared and served today were nutritious, of sufficient quality and quantity, and well presented. Residents able to express an opinion all stated that the food was enjoyable, of sufficient choice and quality. Mealtimes were also said to be flexible and well timed. Assistance was appropriately provided where needed. The kitchen was inspected and the cook spoken to. There is four week menu in place, the food served today differed from that listed but this change was shown on the dining room notice board. Cleaning schedules are in place and were mostly up to date however some issues came to light on inspection. There was some meat in a fridge not dated and another fridge was not clean with some spillage evident also some vegetable remnants. An item of equipment for preparing potatoes was not clean and had caked matter on it. The cook stated that she would rectify these matters. She has recently attended food and hygiene training; the kitchen assistant is to undertake this in the near future. The issues were discussed with the registered manager who stated that a new chef is to be employed and that matters are expected to improve then. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16-18 Residents and most of their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: There is complaints procedure in place and residents spoken to stated that they felt complaints would be responded to if necessary. One relative stated that the home had been very accommodating of any comments he had to make on the changing needs of his relative. The Commission is however in receipt of correspondence from a relative who felt that discrepancies in her account following her husbands death took a very long time to be rectified and that she had not received an apology from the manager. This was discussed with the manager who said she felt a letter of apology had been sent but this could not be produced. She will investigate further and will take appropriate action. Policies and procedures on abuse are in place as is training. Inspection of staff training files however shows that not all staff attend the training. There was discussion on the responsibility of the manager in ensuring that staff attend all mandatory training to ensure that residents are protected from abuse. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,23,26 These standards were not inspected on this occasion EVIDENCE: Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The numbers and skill mix of staff do not always meet resident’s needs. Residents are not supervised at all times therefore cannot be in safe hands at all times. Residents are not supported and protected by the home’s recruitment policy and practices. Not all staff are trained to do their jobs therefore competent cannot be assumed. EVIDENCE: Residents spoken to, who could express an opinion said that staff were kind respectful and caring. Staff were observed caring and interacting in an appropriate manner in the main part of the home. However in the dementia unit there were not any staff in the lounge with the residents and I had to open the fire door to admit a resident who likes to walk in the grounds. The skill mix in this unit was the subject of discussion at the last inspection but no change was observed on this inspection. This was discussed with the unit manager who stated that there is now an activities worker in the afternoons, which is an improvement, but that there has been little change in the supply of kitchen and laundry help in the unit. She further stated that of the staff on the floor one should have been with the residents while the other cleared up after tea. The fact that two staff were also on break was discussed and the need for breaks to be staggered. This was also discussed with the registered manager. The need for a more supervised and therapeutic atmosphere in this unit was stressed. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 15 Staff files inspected did not have the complete documentation as specified in Schedule 2 of The Care Standards Act 2000 (miscellaneous Amendments) Regulations 2004. Criminal Records Bureau clearance and a check against the Protection of Vulnerable Adults list was not in place for four staff, neither was there a full employment history. Staff training records show that not all staff attend mandatory training and this was discussed with the manager who must ensure that this takes place. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Residents 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. Residents benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Residents’ financial interests are safeguarded. Staff are appropriately supervised. . The health, safety and welfare of service users and staff are mostly promoted and protected. EVIDENCE: The registered manager is a Registered Nurse and maintains her registration with the Nursing and Midwifery Council. She is also completing a degree in Community Health Care, which has included a management component. Residents, staff and relatives spoken to and comment cards received mostly Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 17 stated that they are happy with the managements of the home and the response to comments and complaints, (See Standard 16). Resident’s comments are sought on issues such as the menu and activities and there is a survey which is sent out with the newsletter. Money is not handled for residents. The home meets all financial commitments and then bills service users. Staff supervision is in place (known as appraisal) and is carried our quarterly. The need for this to be increased was discussed. Records of this supervision were available for inspection. The health and safety of service users and staff is insured by appropriate Health and Safety policies with systems available to support these. A maintenance man is employed to carry out repairs and routine maintenance. Risk assessments are completed for both the establishment and individual service users. Records of accidents, injuries and untoward incidents are recorded and reported appropriately. Regular inspection by other agencies are undertaken to ensure the safety and maintenance of the home. Training records indicated that not all staff are attending training appropriate to the work that they do and this poses a risk to the health safety and wellbeing of resident as does the incomplete recruitment practices adopted at present. Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 3 3 x 3 3 x 2 Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 19 yes 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 27 Regulation 18 Requirement Timescale for action 01/12/05 2. 30 13, 18 3. 29 19 4. 9 13 the registered person to ensure that suitably qualified, competent and experienced staff are working in the care home at all times and in such numbers as are appropriate to the health and welfare of the residents. This was a requirement of the previous inspection and a new timescale has been given. The registered person to ensure 01/01/06 that there is a staff training and develpoment programme which meets the National Training Organisation workforce training targets and ebnsures that staff fulfill the aims of the home and meet the chaning needs of service users. The registered person operates a 01/12/05 thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The registered person to ensure 01/12/05 that service users are able to take responsibility for their own medication if the wish is within a risk management framework and that they have a lockable space in which to store medication. Version 1.30 Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Page 20 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 Good Practice Recommendations Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 2nd Floor, Ridgeworth House liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Barlavington Manor H60-H11 S14386 Barlavington Manor V244866 031005 Stage 4.doc Version 1.30 Page 22 - 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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