Inspection on 27/06/05 for Barleycombe Residential Home

This inspection was carried out on 27th June 2005.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Barleycombe Residential Home 14/01/08

Barleycombe Residential Home 29/08/07

Barleycombe Residential Home 11/10/05

Barleycombe Residential Home 23/05/05

Barleycombe Residential Home 04/11/04

Barleycombe Residential Home 19/05/04

Barleycombe Residential Home 13/02/04

Barleycombe Residential Home 14/08/03

Barleycombe Residential Home 28/11/02

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

CARE HOME ADULTS 18-65 Barleycombe Residential Home Sudbury Road Long Melford Sudbury Suffolk CO10 9HE Lead Inspector Claire Hutton Unannounced Inspection 27th June 2006 10:45 Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 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 Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Barleycombe Residential Home Address Sudbury Road Long Melford Sudbury Suffolk CO10 9HE 01787 880203 01787 310809 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) West Regent Limited Mrs Joanne Woodhead Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: Barleycombe is a care home for adults with a learning disability and currently only has male residents. The home consists of a two-storey building situated in extensive grounds, which had been cultivated to produce vegetables and maintain livestock. The home was set back from the main road running between Sudbury and Long Melford. Both towns were accessible via public transport, with Long Melford within reasonable walking distance. The owners of the home had produced plans to extend the service by providing a five-bedroom moving on facility. Copies of the plans were submitted to the National Care Standards Commission in 2003, these have since been revised. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that focused upon the key standards relating to Younger Adults. It took place on a weekday between the hours of 10.45am and 6.00pm. The process included a tour of the building, discussions with residents, staff and the manager who was present most of the day, observations of staff and service user interaction, and the examination of a number of documents including residents care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. The report has been written using accumulated evidence gathered before and during the inspection. Eight completed comment cards were received back from relatives/visitors and nine completed surveys were received back from the current resident group. Since the last visit to the home a company called Southern Cross has purchased the care home. At the end of April 2006 a member of the public assaulted the manager in the grounds of the home and she was absent for a number of weeks. These two events were the main triggers to this unannounced inspection. What the service does well: What has improved since the last inspection? Practices relating to medication have improved. A new monitored dosage system has been introduced with better more accessible storage. A new medication fridge was said to be on order. The laundry room has had a wash hand basin installed to enable staff to wash their hands immediately after dealing with laundry. Repairs around the home, such as door handles, have continued to be undertaken. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 6 Access to training for staff has continued with seventeen of the eighteen staff now trained in control and restraint by an approved provider. January and February of this year saw more training in health and safety, fire, manual handling, medication, sexual rights and client welfare. 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. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate. People who use this service currently cannot be assured that information will be readily available to view and up to date, but this is set to improve. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As mentioned in the summary this care home has recently been purchased by a larger organisation called Southern Cross. The CSCI has yet to complete their checks upon the Registered Individual before the certificate of registration is changed. The manager explained that the home was in the process of updating the statement of Purpose and Service Users guide with the relevant changes. A copy of these documents has said to have been forwarded to the commission for their records. The manager explained that the home have purchased a board with a Perspex front in which the home intends to display information to residents and visitors. This will include information such as the Statement and Purpose and Service Users Guide. Since the last inspection one new service user has been admitted to the home. There was evidence of information provided by the placing social worker on how best to meet the individual’s needs. The manager stated that they had completed an assessment of need before the individual was placed at the home. This was not available to examine on the day nor did care staff think they had seen this. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 9 Care staff did say that the individual had had the opportunity to look around the home and spend some time at the home before moving in. Three service users information was examined with regard to contracts and terms and conditions. There was not yet a contract and terms and conditions in place for the new service user. The manager explained that this had been requested and had been chased up. No evidence was seen to support this. The two other service users had been at the home for some time. Contracts were in place as were terms and conditions (dated 1993 and 2001). These were made several years ago and with the previous owners. The home had been seeking a review of one person’s arrangements for a number of years. The manager explained that the new organisation was meeting with the local authority to update those contracts in place. Following this the service users can expect to have a copy of the agreement and arrangements made on their behalf. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Quality in this outcome area is adequate. Residents can expect to have plans developed around their individual needs, however residents may not be supported to make decisions as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents were tracked. All three had a care plan in place that had been developed from an assessment of their daily living activities. There was evidence of review. Risk assessments were seen in place for each individual, one person had just two whereas another resident with more complex needs had ten risk assessments in place. In one plan there were written guidelines in place with a set of rules linked to behaviour. These were written down for staff to know and for them to encourage the resident to follow. Progress on these was noted by staff with the final decision made by a senior member of staff as to whether an individual could for example access the community. This behavioural plan was not dated nor signed by relevant parties. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 11 A later discussion with the manager following the inspection confirmed that this plan had been updated and a new agreement put in place. Another example around decision-making that was not transparent in the care plans was the use of alcohol. There was great discussion amongst residents as a regular trip was being made to the local pub that night. Staff explained that they were encouraged by managers not to allow alcohol consumption at the pub for one resident, although the resident repeatedly requested alcohol. The care plan in this case was not clear for staff as to why they should infringe the residents right to alcohol. This ambiguity is possibly leading to differing approaches by staff on such occasions and could present a difficulty for staff who do impose the restriction. Therefore any restriction upon decision making by residents should go through the assessment process, involve the resident (or their representative), and be recorded in the care plan for all staff to follow and then staff must record instances when decisions have been made by others and why. From the nine surveys completed and returned by residents eight of the nine residents surveyed stated that staff either always or usually treated them well. All nine surveys stated that carers listen and act on what the resident say. Seven of the nine surveys were completed with the help of staff. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. People who use this service can expect a lifestyle that offers opportunities for personal development, leisure and community participation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an activities programme with designated staff and individual resident names alongside times. Activities include care of the animals (with one specific person employed who is appropriate to teach care of the animals), housekeeping, lunch preparation, shopping, cooking, fishing and horticulture. In addition some individuals attend day services for people with a learning disability or college. There was a planned change of hours for one staff member to offer activities on evening during the week. This was in response the resident requests. Each resident had a log of activities undertaken. The amount of appropriate activities on offer to participate in the local community was varied and based around resident’s preferences. Throughout the week there are evening activities. These are trips to the local pub – one was planned that evening, the Legion, Gateway, shopping and swimming. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 13 However swimming had on occasions recently been cancelled due to staff shortages. Residents spoken with were pleased to have the opportunity to go shopping and buy their individual purchases and were pleased to be going to the local pub. At previous inspections to the home a requirement was made to develop a policy around all aspects of relationships, as this was particularly relevant to a group of young men. The area manager developed a baseline policy. The previous request was to have staff and residents consulted on the development and to offer staff training. Nine staff have completed a training course on sexual rights run by Suffolk Social Services. The manager had agreed that the policy would be reviewed in light of the training these staff had undertaken. However since Southern Cross has purchased the home policies and procedures are now provided by that organisation. There was a policy available, but this was developed for older people. This does not address all matters for this service user group at Barleycombe. Residents at Barleycombe are given their individual room key to promote their privacy. Staff asked permission to enter the individual rooms and refusal was respected. Interaction between staff and residents was observed on several occasions throughout the day. Staff were friendly and supportive towards residents and appeared to know them well. In relation to standard 16 please also refer to the previous section on decision-making. The dining room at Barleycombe is comfortable and can accommodate all those who are resident. The manager explained that new dining room furniture was on order. The kitchen is appropriate in size and equipment. A new fridge was said to be on order as the seal on the current one was broken, although upon examination of the temperature recordings an acceptable cool temperature was maintained to store food that required refrigeration. Temperatures of cooked food to be served to residents were recorded, but this was not consistent. The first week in June 2006 had several gaps. There were sufficient stocks of food with fruit and vegetables ordered daily for the next day delivery. Meat comes from a local butchers with all other provisions either delivered or purchased from a local supermarket. There was a three-week rotating menu that provided sufficient variety and choice for residents. In amongst these was a proposed themed dinner party to introduce differing cultures and foods. There was also the occasional barbeque. Residents spoke of the barbeque fondly and staff were aware of health and safety of how to manage such an event. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Residents can expect to have personal and healthcare support that meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst examining one persons care plan there was evidence that their care needs had increased, staff spoken to were aware of this and were actively considering best ways of supporting the individual. This had included revising risk assessments and developing manual handling assessments. Referrals had been made to health professionals to ensure health was monitored. Access to health services was also seen in a second persons file with a referral from the GP to the dietician, blood testing and to a consultant specialising in learning disability. Appointments and outcomes were documented in the daily statements. Recording in the daily statements by staff was appropriate and covered individuals general well being, activities they had undertaken and any professional visits they had made or received. Since the last inspection at the home, Barleycombe has moved on to a different medication system. It is a monitored dosage system on a four weekly card. Staff spoken with were happier with the new system and were confident in using this. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 15 One relative was not completely happy with the new arrangements, this was explored during the inspection process and it was found that the home had made attempts to accommodate individual requests. A member of staff confirmed that all staff who administer medication are appropriately trained. Evidence of nine staff being trained was seen to have taken place in January 2006. It was explained that all staff will have base line training in medication in months to come. A new medication cabinet has been installed to ensure secure storage, lighting and temperature of the room was appropriate. The senior on duty always holds the key thereby ensuring security is maintained. A sample audit was undertaken on one person’s medication. This was all correct with medication administration records (MAR) being completed either with a signature or code explaining the reason the medication was not administered. The home continues the practice of a second staff member signing for medication even though staff are trained and confident. There was a list of sample signatures and initials available to identify the persons administering medication. At the previous inspection the medication fridge did not have the temperatures recorded. This was now in place and appropriate. However, the fridge had been moved from its previous locked cupboard to enable it to work appropriately. This has compromised the security of the fridge, as it does not have a lock. Staff stated that a lockable fridge had been ordered, but this was some time ago. The policy on medication was requested, but this was not available to staff. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. People who use this service can expect to have access to the complaint system if they need it and to be protected from abuse as far as is possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eight of the nine residents who responded to the survey stated that they knew how to make a complaint if they needed to. Staff and manager spoken with at the home were all clear that the home had a procedure for receiving complaints and that it was displayed in the home. Two relatives/visitors were unaware of how to make a complaint if they needed to. The manager keeps a log of all complaints made, the investigation undertaken and outcomes. This was available for inspection and no complaints had been received since the last inspection at the home. The commission’s experience with the registered manager and viewing of the log demonstrates that complaints are taken seriously and acted upon. The home has a protection of vulnerable adults (POVA) procedure in place. They subscribe to the local authority joint working agreement. The commission is aware that the manager is confident with the local procedure for referral to POVA, as they had previously used the system appropriately. Staff have received training in this area. All staff who work at the home have been subject to a criminal records bureau (CRB) check which includes checking the national POVA listing for staff not suitable to work with vulnerable people. Three new recruitment files were examined and the POVA and CRB checks were either completed or in progress. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is poor. The accommodation provided was generally clean and satisfactory, however some repairs are needed to maintain a minimum level of comfort and hygiene practices currently do not protect staff or residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was undertaken. This included four bedrooms, with residents’ permission but did not include the more independent flat. On the whole the home is clean and meets the needs of the residents who live there. However, overall the home is looking tired and in need of the planned refurbishment. A separate extension and the refurbishment of the home has been planned for some time, but due to new owners purchasing the home this has been delayed. The refurbishment will make it possible for each bedroom to have an en-suite. This will be a very positive step as some of the bedrooms are rather cramped and currently unable to provide all the standard furniture such as two comfortable chairs. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 18 The home must be maintained to an adequate standard in the interim. At the last inspection two matters that required attention have not been actioned. This was the cleaning/replacement of carpet in room 5 and the seal on the fridge in the kitchen is still broken and must be replaced. Door handles have been replaced and the laundry room now has a wash hand basin, liquid soap and paper towels available for staff to use. The area around the wash hand basin must be made good to ensure this does not harbour germs; therefore this must either be painted with a washable paint or tiled to enable effective cleaning. The laundry room has suitable equipment to launder clothes, including a two-sluice programme washing machine. Upon discussion it was discovered that the dispenser pump for the washing machine liquid was not working adequately therefore staff were feeding the machine by hand. In order to use the second sluice cycle on 40°c the dispenser pump needed to use a chemical disinfectant. There was none available to use. Further discussions revealed that clothes are on occasion hand sluiced/soaked in the newly installed wash hand basin. All four bedrooms visited contained personal possessions and were individual. In bedroom 12 the wash hand basin was loose and is a potential hazard to the resident, therefore this must be made safe and secure. In the grounds a trench had been dug to accommodate a CCTV system that is due to be installed. This is in response to the recent assault of a staff member and is for security purposes and will not impinge on the resident’s daily life. The protocols developed about the use of the CCTV will be examined at the next visit to the home. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 and 35 Quality in this outcome area is good. Recruitment of staff is robust and offers protection to residents. Residents can expect to be supported by competent and qualified staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing roster for the current week, last week and next week were examined. The roster usually has four or five staff working at any one time during the day this occasionally drops to thee staff, but levels are determined by the activities planned, therefore if residents are going out then staffing would be increased to enable this to happen. An evening a trip to the pub was planned and staffed accordingly. The home currently had three full time care staff vacancies; therefore the roster showed care shifts being covered by staff doing additional hours and use of relief staff and some agency. Minimum staffing levels were being adequately maintained. Care staff were also responsible for cooking at the home, as currently there was no chef employed. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 20 Recruitment for these posts was well under way with staff appointed to all vacancies. The recruitment records for new staff due to start were examined. The manager was clear about ensuring that a robust recruitment process was completed before staff started work. All the appropriate checks were being processed and this included references, CRB and POVA. Since the last inspection at the home training for staff has progressed with nine staff accessing sexual rights training, eight staff completing client welfare training, eight staff completing fire training with a second date in July to ensure all other staff are updated, health and safety, manual handling, first aid and medication have all been completed by staff. In relation to NVQ training the manager states that 57 of staff have achieved or are in the progress of achieving NVQ 2 or 3. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. People who use this service can expect a management that will monitor and review the running of the home and promote and protect health and safety matters. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is appropriately qualified and experienced. She holds NVQ 4 and the Registered Managers Award. She has recently completed a City and Guilds in teaching. In addition her attendance was noted at courses that care staff attend to maintain appropriate updates. Residents and staff were positive about the management of the home. ‘Barleycombe is marvellous’ stated one resident in their survey. The home was in the process of a quality assurance audit introduced by the new owners. A resident questionnaire had been completed by all residents and six questionnaires returned from relatives. The manager explained that the information was currently being loaded onto a spread sheet and would go to head office, this would then be fed into the operational plan that was being Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 22 developed, therefore the wider organisation is monitoring and taking responsibility for the development and improvement of the home, not just the staff and residents who work and live there. Currently there is a residents meeting once every three months and it is intended that this will be every month along with developing a relatives forum at the home. These developments are welcomed, as the home is to go through a big period of change with refurbishment and the new build in the grounds. Consultation with interested parties will benefit the home. Staff must also be kept up to date on changes. During the inspection staff spoken to had conflicting information about the planned changes, this was discussed with the manager who agreed to inform them of current plans. Regulation 26 visits, which are monthly unannounced visits by the owners, are regularly completed and a copy of the report is forwarded to the commission on a regular basis. A number of health and safety matters and training have already been addressed throughout this report. A number of records relating to maintenance and health and safety were examined and found to be in order. The new organisation had just issued comprehensive guidelines and recording formats on several health and safety matters. These have yet to be introduced at the home. An immediate requirement to have the annual service the fire alarm system, fire extinguishers and emergency lighting was left at the home, as this had not been completed since May 2005. An immediate response was received from the organisation stating this was scheduled for July 2006. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 24 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 YA2 Regulation 14 (1) Requirement New residents must only be admitted on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. These must be available for inspection and to staff at the home. (This is a repeat requirement from 11/10/05) Timescale for action 31/07/06 2. YA5 5 (1) The registered manager must 31/07/06 develop and agree with each prospective resident a written and costed contract/statement of terms and conditions between the home and the service user. If this is through the local authority then the service user must have a copy of the agreement and arrangements made on their behalf. (This is a repeat requirement from 11/10/05) Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 25 3. YA7 15 and 17 The care plan must describe any 31/07/06 restriction or sanction on choice and freedom and must be made in agreement with the resident (or their representative). Residents rights to make decisions are only restricted through assessment and must be recorded in their individual care plan. (This is a repeat requirement from 10/02/05, 23/05/05 and 11/10/05) The home must ensure that the storage of medication is appropriate; therefore a lockable medication fridge must be obtained. The home’s policy on medication must always be available to staff and for inspection. 31/07/06 4. YA20 13 (2) 5. YA24 23 (2)(b) 6. YA30 16 (2)(j) The home must be kept in an 31/07/06 acceptable state of repair as agreed and detailed in this report. The laundry room must have the 31/07/06 area around the wash hand basin made good to ensure effective cleaning. The washing machines must be repaired and able to supply the appropriate cleansing fluids to adequately clean clothes, including the sluice cycles. Staff must not hand sluice or soak soiled linen, but be trained appropriately in dealing with foul laundry. Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 26 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 YA15 Good Practice Recommendations The policy on relationships and sexuality should be reviewed in light of: • Staff training to ensure the training and instruction from policy match. • The organisation policy being for older people. The temperature of hot food served to residents should be measured and recorded on a regular basis. 2. YA42 Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Barleycombe Residential Home DS0000024331.V294738.R01.S.doc Version 5.1 Page 28 - 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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