Inspection on 11/05/05 for Barleycroft Care Home Ltd.

This inspection was carried out on 11th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Barleycroft Care Home Ltd. 18/03/09

Barleycroft Care Home Ltd. 18/04/07

Barleycroft Care Home Ltd. 20/12/06

Barleycroft Care Home Ltd. 02/06/06

Barleycroft Care Home Ltd. 26/08/05

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Barleycroft Care Home Ltd Spring Gardens Romford Essex RM7 9LD Lead Inspector Rhona Crosse Unannounced Inspection 11 May 2005 09:30 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. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Barleycroft Care Home Ltd Address Spring Gardens, Romford, Essex RM7 9LD 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) 020 8504 6565 Festival Care Homes Ltd Jennifer Martin CRH Care Home 80 Category(ies) of DE Dementia registration, with number DE(E) Dementia - over 65 of places OP Old age PD Physical disability PD (E) Physical disablity - over 65 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration placed on this home. Date of last inspection This is the first inspection undertaken to the home since it was registered in January 2005 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Barleycroft is a purpose built home owned by Festival Care Homes Ltd. providing 24 hour nursing care for 80 service users with physical disabilities and dementia. All bedrooms are single occupancy and all have en-suite facilities. The home is situated off the Romford Road. There are bus routes close to the home into Romford market town. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The home was registered in January 2005 and was purpose built. This is the first inspection of the home since it’s registration. At this inspection not all standards were inspected. The report identifies which standards will be inspected at other inspection visits. During this unannounced inspection, care plans, risk assessments and health care needs formed the majority of the inspection. Discussion with service users and relatives as well as observation of the first service user’s/relatives meeting formed part of the inspection process. It is of concern to the Commission that the completion of documentation is poor and the content is also poor. Therefore this places service users at risk. What the service does well: What has improved since the last inspection? What they could do better: The Commission has concerns about the completion of documentation and the information provided in relation to the ongoing needs of service users. Care Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 7 plans, risk assessments, food and fluid charts and the daily record entry on admission were not appropriately completed with important information about the needs of service users either not identified or not updated as changes occurred. Four days of daily records relating to a current adult protection investigation are missing, despite the manager reading from one of the records the day she photocopied this file for the inspector (4.5.05). At this unannounced inspection the manager stated that she had still not found these documents. On two occasions the Commission were not informed of significant events that had happened in the home. The Commission must be informed under Regulation 37 of these events. Any further failure to report significant events to the Commission may result in formal action being taken. The registered providers are to be asked to attend a meeting with the Commission to discuss the concerns raised from this first inspection. 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. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5. Standard 6 does not apply to the home as they do not provide this service. This standard is met in relation to the assessments being undertaken prior to admission and information provided to service users. However, copies of contracts and terms and conditions of residence should be held on service users files. EVIDENCE: The home carryout a pre assessment visit to all service users and this is documented and held on service users files along with the placing authorities assessment. However the random selection of files inspected did not have copies of contracts or terms and conditions of residence held in the files. A copy of either a contract or terms and conditions should be held on each individuals file. Relatives and prospective service users are provided with information telling them about the service the home provides (Statement of Purpose and the Service User’s Guide). Relatives are able to visit the home prior to admission. Standard 6 is a service that the home do not provide. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 10 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10. Standard 9 was not inspected due to the Pharmacist visiting at the time of inspection. This standard will be inspected at the next inspection as will standard 11. The documentation relating to care planning and risk assessments, food and fluid charts were poorly completed. This places service users at risk as the information held does not provide sufficient information for staff to care for service users appropriately. This standard is not well managed and requires a lot of work to bring the documentation up to the National Minimum Standard. It is concerning that nurses who are required by the Nursing Code of Conduct to provide accurate nursing records are not doing so. The manager must monitor all records to ensure that the Regulations are being complied with. EVIDENCE: A random selection of service users files were inspected. These included daily records, care plans, risk assessments and general information held in individuals files. Care plans were not updated in many cases and information held did not correspond with the information provided at assessment or correspond with changes recorded in the daily records when these were cross referenced. It was stated that new documentation had been put into place and Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 12 therefore some information was different in some service user’s files. However, one service user (A) who had been living at the home for some time had blank care plans with nothing completed. When the second file (said to hold archived information) was inspected, no old care plans were held in this file. For service user (B) (identified as being physically aggressive) the risk assessment for behaviour was inadequate, as this did not detail the specific actions staff should take if the service user became aggressive to other service users or staff. Clear (preferably step by step) instructions must be recorded to ensure all staff know exactly how to deal with behavioural problems that may arise. From cross referencing other documents it was established that this service user is now having medication by injection. This is not reflected in the behavioural care plan. The same situation was found in another file for service user (C) when after an episode of physical aggression, (found recorded in the daily records) the care plan and risk assessment had not been updated and changed to reflect this. For service user (D) who has a catheter in situ there was no care plan for this. The GP visits record sheet documented that a bladder wash out was required twice a week. There were only two recordings of this bladder wash out being undertaken, one recorded on the 29/4/05 and one recorded on the 6/5/05. The home has to evidence from the nursing records the care they provide. There is reference made to the use of a slip sheet and air mattress being put into use, however the pressure care plan does not record this change. The service user also required a “pain” care plan and is taking Morphine Sulphate and Oramorph for pain. There had been no new update of the pain control chart since the last entry made on 17/3/05. The dependency score level of this service user was deemed to be low yet this person has a terminal illness therefore the dependency score should reflect this fact, it did not reflect this. For service user (E) the nutritional assessment had not been completed, but information cross referenced from other documentation identified that this service user requires the food intake recorded and there had been a substantial weight loss of 1 stone 4 lbs. but the care plan does not hold this information. A fluid chart held information about the diet taken, however the information provided did not provide in enough detail the meals consumed. There must be a separate food chart recorded if there is a concern. However, good recording was observed for this service user; the skin viability care plan was completed and the care plan was updated monthly. For service user (F) this person has oedema to the lower legs and feet, there is no care plan for this condition. For service user (G) who left the building and was trying to climb the perimeter fence, there is no update in the care plan to ensure the service user’s safety despite further entries in daily records of leaving the building by fire exits. These errors mean that those service users are at risk. Fluid charts were not appropriately completed. There is no individual amount of fluid record on the sheet to identify the optimum amount of fluid that an individual should take to keep them adequately hydrated. Fluid charts were not totalled and all entries stopped at 19.30. A fluid chart should cover a 24 hour period. From the records held the home cannot evidence that service users are Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 13 being provided with enough fluids. Although medication practice and recording was not inspected (due to the pharmacist carrying out an audit of current service users medication at the time of the inspection), it was observed from past medication administration sheets that an antibiotic for one service user did not have the amount of medicine received by the home recorded. Another antibiotic stated that 14 tablets were received, however the medication administration sheet recorded 17 signatures. No explanation could be provided by the manager. For a service user who has Epilepsy the medication administration sheet recorded the code ‘O’ used to state the medication Sodium Valporate 500mgs 1 tablet to be administered twice a day was not administered on the 19/4/05, 20/4/05 and 26/4/05 at 22.00 hours. Also the medication Phenytoin 100mg capsules 2 to be administered twice daily also had the code ‘O’ used to state they were not administered at 22.00 hours on the 19/4/04, 20/4/05 and 26/4/05. The manager read the daily records and stated to the inspector that there was no entry recorded to say why the code ‘O’ was used and the medication not administered. Also for the 20/4/05 08.00 the medication Phenytoin 100mg capsules has no signature to show the medication was administered at that time. Medication must be administered as prescribed at all times. The entries made at the time of admission in the daily records do not hold the information required, such a medical needs, (epilipsy, catheter care, diabetes, behavioural problems), current medication. This is poor practice and must be changed. The daily records must show the current needs of each service user at the time of admission to adequately inform staff of their needs. From documentation of contact with GP’s and other health professionals this information showed that attention was being paid to medical changes in service users health with appropriate referrals being made at the time of the inspection. Privacy and dignity were observed to be respected throughout the day. However, as there are male carers each service user should be asked at the point of admission what their preference is to male or female staff caring for them in relation to personal care. It should not be taken for granted that everyone would be happy to accept a different gender of carer. This must form part of the admissions process and service user’s preferences must be identified in their care plans. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 14 were inspected. Standard 15 was not fully inspected but will be inspected at the next inspection. Some of the areas in this section were well managed, (the home provides 2 activities co-ordinators. sensory room provided, social histories are being completed, food portions were of a good size and a choice of meals was provided). Others require attention to detail that will make significant changes to service user’s daily life as identified in the body of these standards. EVIDENCE: Relatives and friends are able to visit service users at any time. There no restrictions placed on visiting time. However there have been recent changes to where relatives can sit with service user’s when they visit. Not all relatives were supportive of this change and raised this during the service user’s and relatives meeting. Restrictions have been placed on relatives sitting in the main lounge with service users and they have been asked to go either to the bedrooms or use the quiet lounge when visiting. Whilst there is no regulation that can override this decision made by the manager, it is the service user’s home and therefore where they wish to receive visitors should be taken into consideration. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 15 From a random selection of service users files it was observed that some files hold a social history that is very helpful when activities are being organised. A local Church visit the home and also a Catholic priest makes individual visit to service users. There are two activity co-ordinators and activities are either 1-1 or group activities. Service user’s have the choice of whether to join in these activities or not. Each service user has an activities record, refusals to join in the entertainment were observed to be documented along with activities that had taken place. Birthdays were said to be celebrated with a present, card and birthday cake from the home. Outside entertainers are being brought into the home and there has been an entertainer visiting the home in April and May (10/5/05). The home has a ‘sensory room’ which aids people with dementia to relax. Service users are given a choice of whether to sit in the main lounge or use their bedrooms. Several service users prefer to spend their day in their rooms. Others were observed to go to and from their bedrooms during the day. There is a lack of specific activities designed for people with dementia. The home must provide more reminiscence material and reality orientation material. Staff should be specifically trained to provide activities for people with dementia. The home should look at what specific training is available. These areas must be addressed. The inspector observed the serving of the main meal of the day. There was a choice of chicken breasts or roast lamb, vegetables were carrots and cauliflower (fresh vegetables) and mixed vegetable (frozen vegetables), roast and mashed potato. Bread and butter pudding followed, alternatives were ice cream or yoghurt. Portions were generous and service users appeared to have good appetites. The pureed food provided was a brown ‘mush’ all pureed food should be blended separately to keep individual flavours and colours as well as making the meal look well presented and appetising. This should be addressed. Good practice was observed as the activities co-ordinator was seen taking photographs of meals which will be put into a food diary to show service users who have no speech or very little speech what meals the home are providing, giving these service user’s a real choice. One service user stated ‘there is no salt here’ another service users said ‘ I don’t like salt’ anyway. There was no salt and pepper available to service users to use, this should also be addressed with individual salt and pepper pots for each table. Breakfast was recorded as a range of items from cereals, toast to a cooked breakfast. A record of meal choice is kept. This area was well managed. A male carer was observed to be standing up feeding a service user. This is poor practice and was brought to the attention of the nurse in charge of the unit. Other staff were observed to be seated when they were feeding service users. In discussion with service user’s during lunch they said ‘we like the food, but we would like more fresh fruit at meal times, fruit and custard, grapefruit or prunes or fruit juice at breakfast’. They said that they were going to raise this at the meeting later that day, (which they did). Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18 however these standards will be inspected further at subsequent inspections. This area is poorly managed. There must be significant improvements made. Records are missing that relate to an adult protection investigation and it is said by the manager that they cannot be found. Further searches must be made within the home to locate these documents. (It is a regulations that no records must be destroyed until 3 years after the last entry is made on them). EVIDENCE: The home have a complaints policy and procedure as well as policies and procedures for the protection of vulnerable adults. A relative who raised a concern with the home felt that the explanation given to her by the home relating to the care of her mother was not satisfactory. The service users was admitted to hospital. This was referred to the Social worker and then passed to the Adult Protection Co-ordinator for Havering and the Commission for Social Care Inspection (CSCI). The home is currently being investigated under the Adult Protection Procedures. It is of concern to the Commission that four days of records are missing from the file of the service user the complaint has been made about. The manager photocopied the entire file of the service user. However entries stop after 06.00 on the 16/4/05, there are no records for the rest of that day or for the 17/4/05, 18/4/05 and 19/4/05. There is part of an entry recorded on 20/4/05 that continues on the same page with an entry made for 21/4/05. The manager states that these documents cannot be found yet she read from the daily record of the 20/4/05 in the presence of the inspector on the 4/5/05 when she photocopied the file. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 17 Service users finances were not inspected at this inspection but will be inspected at subsequent inspections. Any expenditure made on behalf of the service user for newspapers, hairdressing, toiletries can either be invoiced as part of the overall charges or money can be held in safekeeping by the home. Accounts of any expenditure will then be provided to relatives. Service users are placed on the electoral role. Postal voting was available to service user’s. One service user who was able to vote chose not to and the ballot paper was then destroyed. This was observed recorded in the daily records. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 were inspected. The majority of the standards in this section meet the requirements of the National Minimum Standards and are well managed. However as this home cares for people with dementia there is little in the way of ‘sign posting’ to guide service user’s around the units other than all bathrooms and W.C.’s having the door frames painted the same colour. This is an area that needs to be addressed. Activity material specifically designed for people with dementia needs to be provided (it was said that only puzzles and quiz material have been purchased). Clinical waste was well managed within the home, however the clinical waste bins outside the home were found with both lids open, this is poor practice and must be addressed. EVIDENCE: The home is newly built and therefore there are areas that will require attention and are still within the ‘snagging’ timescale so the builders will return to correct any problems. The grounds are accessible to service users and are secure so that service users can wander in safety, however they would still Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 19 require monitoring by staff. Some shrubs have been planted and the manager stated that the garden is to have a patio area and more bedding plants. A random selection of bedrooms were inspected, as were the en-suites of the bedrooms, these were found to be clean and free from odours. Beds were well made and linen was clean and well ironed. Bedrooms held a lot of personal possessions and small pieces of furniture that service users had brought with them to make the rooms more homely. One service user who was in her bedroom was looking forward to having shelves put up by the maintenance man that her relatives had bought so her belongings could be displayed. There is a crack in the window pane of bedroom 19. This has been raised with the builders and the home is awaiting a replacement window. Bathrooms, shower rooms and W.C.’s were clean and free from odours. The door frames of these rooms are all painted the same colour to orientate service users to these areas. However apart from photos on each service users doors there is little to distinguish which part of the home you are in. Further thought needs to be taken to identify the different corridors on each floor. Each floor has a main lounge a dining room and a quiet lounge. Furniture was appropriate for the needs of the service users. There is a sluice room on each floor. The downstairs sluice room had no soap available to wash hands (although there was an alcohol hand lotion available). The home has specialist equipment for lifting and handling with different slings for hoists and other lifting equipment and aids and adaptations for the needs of the service users. Some service users have specialist beds and mattresses to aid the pressure relief. The home has a call alarm system. All bedrooms are fitted with appropriate locks. The laundry room was not inspected at this inspection but will be inspected at subsequent inspections. Clinical waste was appropriately stored in the home. However the outside clinical waste store had two clinical waste bins with the lids open. Clinical waste bin lids must be kept closed at all times. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 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 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. Standards 28, 28 and 30 will be inspected at subsequent inspections. Staffing levels were appropriate to meet the needs of service users’ at the time of the unannounced inspection. EVIDENCE: The staffing levels were appropriate for the needs of the service users being 2 trained nurses and 4 care assistants to each floor. There are also administration staff, domestic staff and cooks and kitchen staff. There is a mix of age, skills and gender among the staff group. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 33 and 38(not fully) was inspected. The home is appropriately insured. As service user’s meetings/relatives meetings are taking place this is good practice. However concerns raised during the meeting must be addressed as the interests of the service user’s are not being safeguarded. Notification of significant events must be made to the CSCI this area is not well managed. EVIDENCE: The home has a current public liabilityinsurance certificate and the renewal date is 9/1/06. On the day of the unannounced inspection a service users’ and relatives meeting was taking place. The inspector joined the group for part of the meeting. Approximately 17 relatives came to the meeting held in the afternoon. Several areas of the operation of the home were discussed with the Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 22 manager giving an overview of what the home hopes to achieve. One of the activities co-ordinators spoke about the activities that the home are providing and asked for photographs from the past to create memory diaries for service user’s. New meal times were discussed along with staffing levels and the monitoring of service users in the lounge downstairs, at the relatives meeting. There had been an instance when on one day a relative said she was in the lounge for 40 minutes with no staff present. It was said that service users were asking to go to the toilet or be given a drink the relative said she could not find any staff. Also on another occasion an agency staff member was seen asleep in the lounge by a relative. The manager asked that any complaints or concerns be raised with her at the time of the event to ensure that these are dealt with appropriately. The home are required to inform the Commission of any significant event/accident that has happened in the home. On two occasions this requirement has not been complied with. The home must ensure that all reportable incidents are notified to the Commission. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 3 1 x x 2 x x x x 2 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 24 Are there any outstanding requirements from the last inspection? This is the first inspection since registration in January 2005 STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard OP7 OP7 OP8 OP8 Regulation 15(1) & (2) 17(1)a schedule 3(K) 17(1)(a) schedule 3 (k) 17(1)(a) schedule 3(k) 17(1)(a) schedule 3(k) 13(2) 16(2)(m) 617(2) schedule 4(11) Requirement Care Plans must identify all the needfs of service users and be updated as changes occur. Risk assessments must be appropriately completed and updated as changes occur. Food and fluid charts must be seperate documents Fluid charts must cover a period of 24 hours and be appropriately completed to show a fluid balance. Information recorded in the daily records on the day of admission must identify all of the relevent needs of the service user. Medication must be administered as prescribed. Timescale for action 30/6/05 30/6/05 30/6/05 30/6/05 5. OP9 6. 7. 8. OP8 OP12 OP12 9. OP18 17(1)(a) 11/5/05 and ongoing action. 11/5/05 Ongoing action The home must provide activities 11/5/05 that are suitable for people with and dementia. ongoing. Complaints must be recorded 30/7/05 and the action taken and the outcome also recorded stating whether the complainant was happy with the outcome of the investigation Records must not be Ongoing Version 1.30 Page 25 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc 10. 11. 12. OP19 OP26 OP26 schedule 3(m) & 17 (1)(4) 23(2)(b) 13(3) 13(3) lost/disposed of until 3 years after the last entry has been made, Replace the cracked window pane in bedroom 19 Ensure soap is avaiable for hand washing in the sluice room downstairs. The lids to the external clinical waste bins are to be kept locked at all times. The home must be run in the best interests of the service users. Action taken in relation to the issues raised in the service users/relatives meeting must be addressed and the action taken provided as part of the minutes of the meeting. The home must inform the CSCI of any significant event. action. 30/5/05 11/5/05 11/5/05 and Ongoing action 30/6/05 13. OP33 112(1)(a) 14. OP37 37 Ongoing action as these occur. 15. 16. 17. 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. 2. 3. 4. Refer to Standard OP2 OP15 OP15 OP15 Good Practice Recommendations A copy of the contract or terms and conditions should be held on each service users file. Pureed food should have the vegetables and meat blended seperately to provide a colourful and appetising meal. Salt and pepper should be provided on each table. Staff should be seated when assisting service users to eat. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ferguson House Ilford Essex IG1 4PU 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 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V226599_110505_Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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