CARE HOMES FOR OLDER PEOPLE
Barleycroft Care Home Ltd. Spring Gardens Romford Essex RM7 9LD Lead Inspector
Ms Rhona Crosse Key Unannounced Inspection 2nd June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Barleycroft Care Home Ltd. Address Spring Gardens Romford Essex RM7 9LD 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) 01708 753476 joga@festivalcare.com Festival Care Homes Ltd Care Home 80 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0) Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Total number of beds 80 to be used flexibly amongst the various categories. With the following categories: Old age, not falling within any other category (OP) either sex Residents 50 years of age with a diagnosis of Dementia (DE) either sex Residents 65 years of age with a diagnosis of Dementia DE(E) either sex Residents 50 years of age with a Physical Disability (PD) either sex Residents 65 years of age with a Physical Disability PD(E) either sex One Resident 40 years of age with a Physical Disability (PD) 3rd May 2006 Date of last inspection Brief Description of the Service: Barleycroft is a purpose built care home providing 24 hour nursing care to 80 service users. All accommodation is in single occupancy rooms each with an en-suite. The home is arranged over three floors. There is a passenger lift to all floors. The home is situated near Romford and is on a good bus route to other local areas. Romford has a British Rail Station. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced therefore the home did not know the inspector was coming. The inspector arrived at approximately 09.30 and stayed for the day. The manager was not at the home when the inspector arrived. The nurse in charge of the ground floor met with the inspector and gave informative information about the current situation in the home and was very professional whilst doing this. The manager arrived shortly afterwards having had a previous appointment to attend to. Since the last key inspection there has been a new manager employed. The new manager must put forward an application to register with the Commission. There have been a lot of changes since the new manager has taken over the running of the home. The manager and staff have worked hard to turn the home around and the home is now operating to an appropriate level. There is still a lot of work to be done but overall the changes have benefited the service users. Some documentation that the administrator deals with could not be found after the administrator had left for the day. The home was asked to fax copies of the documents required to the Commission. What the service does well:
The home is becoming more open and there is a positive approach in the home. Information provided by relatives and visitors is now listened to. Relatives meetings take place and relatives are now more involved, with one relative taking the minutes of the meetings. A news letter is now being published every 2 months with information about the home and the activities taking place. There is an open evening where a talk for relatives about dealing with dementia is to be given by a person from the Alzheimer’s society. This is to take place on the 8/6/06. A fund raising event is to take place to support St Francis Hospice on the 15/6/06. Activities are taking place and staff spoken with stated that they are now involved as well as the activities co-ordinator. Every Thursday afternoon service users can go the quiet lounge and take place in discussions or other activities between 2 and 4pm. One of the newly admitted service users said that she had gone to this afternoon activity and had enjoyed it. She stated that she had met a service user there who she used to know when she lived in the community.
Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 6 The ongoing maintenance of the home has improved, particularly the garden. Garden furniture is to be purchased. In discussion with relatives they stated: ‘the home has improved, they keep us informed when mum is not well and really provide a good service. We have no complaints, if we have a concern we speak to the staff or the manager and it is sorted out’. Other comments were ‘they make you feel welcome now’. ‘We visit a lot someone comes in nearly every day so we see the home at different times, we don’t say when we are coming, we just turn up’. ‘There are no restrictions on visiting times’. ‘Mum is kept clean and tidy they do activities but mum is not interested’. Any complaints received by the home are documented and the action taken to investigate the complaint is recorded along with whether the complainant is happy with the homes investigation. There is always a choice of menu at meal times service users are asked the day before what they would like for their main meal. Service users likes and dislikes were also recorded in their care plans and staff were aware of these. The manager has put in place a ‘sickness’ monitoring system and a back to work interview. Since this has been in place there has been a drop in the sickness record of the home. This is seen as good practice. What has improved since the last inspection?
A great deal has improved since the last inspection. The atmosphere of the home has improved and staff are now more focused about the tasks they should be completing. There is a daily work schedule and staff are allocated particular tasks to complete during their shift. This is good practice as staff are responsible for certain areas and work undertaken can then be monitored more easily. The home has recruited a deputy manager and he is due to commence duties soon. At the time of the inspection all of the care plans were being reviewed and updated. Each service user is being reassessed by the nurse in charge of each of the units and their current needs are being updated and recorded. Care plans were at various stages of completion and the newly completed plans had not yet been audited to ensure all information was correct. This inspection will take this change into consideration. However requirements will be set in relation to some missing information in care plans to ensure the ongoing well being of service users. Meals and meal times have improved. Pureed diets are now liquidised separately to show the colours and textures of each individual vegetable and
Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 7 meat/fish/poultry provided. Tables were appropriately set and salt and pepper and other condiments were available which had not been the case previously. Staff were observed to assist service users with their meals and where a service users needed to be fed this was done appropriately with staff sitting next to service users and feeding them at the service users pace of eating. Service users spoken with stated: ‘I like the meals you get enough to eat’. ‘The food is good and you get plenty, you can ask for more, but I don’t’. The cleanliness of the home has improved and at the time of the inspection there was no smell of stale urine in the home. Bedrooms were clean and tidy. Service users had access to there rooms and went to their rooms when they wished. 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. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 3. Standard 6 does not apply to this home. The quality outcome area is good therefore there are more strengths than weaknesses. This judgment has been made using available evidence including a visit to the service. All appropriate documentation was in place. The documentation showed that new service user’s needs can be met before they are admitted into the home. EVIDENCE: Prior to any service users being admitted to the home the home carry out an assessment of the needs of the proposed service user. The documentation inspected for new service users recently admitted showed that this takes place. Information is also provided by placing authorities, these documents were observed to be held on file. Each service user has either a social services contract or if privately placed a contract is provided by the home. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 The quality outcome area is good therefore there are more strengths than weaknesses. This judgment has been made using available evidence including a visit to the service. Documentation is being reviewed and updated to ensure the needs of service users can be appropriately met. EVIDENCE: As stated in the summary of the report the care plans for all service users are being reviewed and updated to ensure that their needs can be appropriately met. The nurse in charge of each unit is carrying out this task. Some care plans have already been updated and others are part way through this process, some have not yet been reviewed. Due to this the inspector will give some leeway to the process as a great deal of work is still to be accomplished. For one service user who shows challenging behaviour there was not a clear written plan to show staff how to deal with this behaviour. It is imperative that all staff deal with any challenging behaviour for this particular service user in the safe way. This is for the protection of the service user, other service users and the staff themselves. There is a behavioural plan that shows the times of challenging behaviour and from observation of this there is a pattern
Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 11 emerging. The care plan should identify the ‘triggers’ and also how to reduce the escalation of these ‘triggers’ and may reduce the challenging behaviour. In discussion with the nurse in charge of the unit it was established that he had not attended any training in dealing with challenging behaviour. He said that he is to attend the next course planned. For another service users there was no care plan for Epilepsy drawn up, this must form part of the new care plan process. For a service user who has diabetes and was recently admitted to the home, the blood sugar monitoring for this person states in the care plan it should be carried out twice a day, but this was not being achieved. The monitoring of the blood sugar must take place as per the instructions on the care plan. For other service users the diabetic monitoring records were up to date. For one service users who was being provided with physiotherapy this course has not ceased but the care plan still records this as taking place. Once the new assessments take place this will no longer feature in the care plan. For one service user newly admitted, the care plan relating to their wishes at the time of death still needs to be completed. As part of the ongoing review of needs this area should be completed for all service users. For one services users newly admitted the home failed to take the person weight as this is part of the admission process this should be completed. As the service user has dementia it is imperative that all records are completed, particularly if there is concern about weight loss due to lack of eating. Health care needs were well recorded with visits from the GP and other health professionals necessary. Specialist feeding records were inspected and these were found to be appropriately completed. From observation of daily records these showed how service users had spent their day and any health concerns and other observations were well documented. It was observed that a member of staff had written ‘Be/4’ instead of the word ‘before’. All records in the home are legal documents and therefore no abbreviations should be written in these records. The medication practice of the units was inspected. On unit 2 medication was observed to be wrongly recorded. The medication Flucloxacillin 500mgs capsules were prescribed, however this was changed to syrup. The capsules were returned but the medication administration sheet was not changed to show Flucloxacillin syrup was now being administered. Staff were continuing to sign the medication administration record stating that capsules were being administered, this is poor practice. A new medication administration record was completed by the nurse in charge of the unit after this was pointed out by the inspector. For another medication administered once a day in the morning this, had been signed a day in advance. Greater care is required when signing
Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 12 medication administration sheets. Medication on the other units was appropriately signed for. It was observed that staff took service users privacy and dignity into consideration talking to them quietly when they were to carryout any personal care. One service user had stains on her jumper and she was encouraged to go with staff to change her clothing. Service users were observed to responded well to staff that were caring for them. A service user spoken with said ‘I choose the clothes I want to wear and I can chose to be in my room, I like company so now and again I go down for food’. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome area is good therefore there are more strengths than weaknesses. This judgment has been made using available evidence including a visit to the service. There have been steady improvements in these areas that will enhance the lives of service users. EVIDENCE: Activities take place on a regular basis and every Thursday afternoon between 2pm and 4pm service users who wish to be involved go down to the quiet lounge. One service user newly admitted said that she had gone to the afternoon get together and had met a person she knew when she lived in the community. Staff are now involved in providing activities and activity material is now available on all units. In discussion they stated the activities they did such as board games, dominos, discussions about old times and music. However as they are not recording these therefore the home cannot evidence the work that is being undertaken. All activities that take place should be recorded. Discussion with the manager took place about service users using the garden in good weather and garden furniture is to be purchased. The home must ensure that the garden area used is safe and that service users can wander without leaving the grounds of the building.
Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 14 Relatives were seen to visit at any time and this was confirmed in discussion with them. Service users are given as much choice as there abilities allow. As many of the service users have dementia the information held in the care plans if very important as it informs staff of their likes and dislikes and times of going to bed. Service users are able to stay in bed and rise at the time they choose. Once service user who had been wandering during the night was seen resting in his room. Other service users went to their rooms as and when they wanted to. Some service users choose to eat their meals in their bedrooms and 3-4 do this on a regular basis. Meals and menus were inspected and a choice of meal is provided. Records of meal choices are kept and a variety of meals were observed to be provided. Meals were well presented on the unit that the inspector was in at lunch time. Comments about the food from service users were: ‘I like the meals, you get enough but you can have more if you ask’ I don’t want more I get enough’. ‘You get a choice at meal times’. ‘I don’t like mince beef, you can’t have anything else’. When the service user was asked further questions it was found that she had not told the staff that she did not like minced beef and had not requested any alternative. The heated trolley on the ground floor could not be taken to the kitchen due to problems with the wheels. The food was brought from the kitchen and dished out from the heated trolley. A new trolley has been ordered and the home is awaiting delivery of this. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome area is good therefore there are more strengths than weaknesses. This judgment has been made using available evidence including a visit to the service. Relatives felt that complaint made are acted upon and their opinions are now taken seriously. This in the long term benefits the service users quality of life. EVIDENCE: The home has a complaints policy and procedure. This is available for staff to refer to at any time. Any complaints received by the home are documented and the action taken to investigate the complaint is recorded along with whether the complainant is happy with the homes investigation. From observation of complaints received this appears to be working well. Of the 4 complaints recorded all had been dealt with appropriately. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 16 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 the following standard(s): The quality outcome area is good therefore there are more strengths than weaknesses. This judgment has been made using available evidence including a visit to the service. The home is well maintained this enhances the well being of service users. EVIDENCE: The home was clean and tidy and free from any odours at the time of the inspection. A random selection of bedrooms were inspected and found to be clean and free from odours. Beds were appropriately made. Service users being cared for in bed looked comfortable and staff monitored them from time to time. Pressure relieving mattresses were observed to be in use. One service user spoke about the specialist mattress saying ‘when I move it moves it feels strange but I am getting used to it now’. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 17 Aids and adaptations are provided in bathrooms and W.C.’s. Lifting aids of different types are also provided. Service users are encouraged to make there bedrooms more homely and many of the service users bedrooms are filled with personal possessions. Clinical waste was observed to be appropriately stored awaiting collection. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality outcome area is adequate therefore there are more strengths but there are particular areas of weakness. This judgment has been made using available evidence including a visit to the service. The new manager is working towards ensuring that all staff have been trained to provide appropriate care. Missing information relating to staff employment are the weaknesses in this section that must be addressed urgently. This is to ensure that the ongoing well being of service users is protected by appropriate recruitment information be available for inspection at any time. EVIDENCE: The home had appropriate numbers of staff at the time of the inspection. Staff are now designated work for the shift they cover. This is seen as good practice as all staff are aware of what they must achieve during their particular shift and the process of monitoring work completed is also easier. The staff files are currently being audited to ensure that all information is held as required by legislation. An inspection of 4 new staff files was made. All staff employed must have 2 written references. However two staff files did not hold second references. The manager stated that she had seen these references but these could not be found. The administrator had left for the day. The manager must fax copies of these references to the Commission. For another staff member the whole file could not be found. The manager must check with the
Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 19 administrator where this information is. All employment documentation must be available for inspection at any time. 10 of the staff hold the NVQ level 2 qualification. A further 8 Staff hold NVQ level 2 training or above. The home is aware that 50 of the staff must hold NVQ level 2 training. The new acting manager has improved the training offered and is ensuring that all staff have the appropriate training to carryout the tasks they are employed to undertake. Staff training is being audited and training has been provided this year. Dementia training took place on the 17/3/06 including nutrition and dementia for 15 staff. 5 staff have undertaken training in dealing with bereavement on the 5/4/06. A care plan work shop took place on the 6/4/06 for 10 staff and a further 5 staff undertook this on the 20/4/06.Manual handling training has been provided for 18 staff on the 15/2/06 and for a further 12 staff on the 28/2/06 and for 4 staff on the 10/4/06. Two staff are to attend training that will enable them to be in-house manual handling trainers. They will commence a 4 day course on manual handling on the 9/6/06. Health and Safety training which incorporates food hygiene, basic first aid and COSHH training (control of substances hazardous to health) and fire safety took place on 5/4/06 for 8 staff and a further 10 staff took this course on the 11/4/06. Managing aggression training took place on the 9/5/06 and 15 staff took this course. POVA (protection of vulnerable adults) training took place on the 7/5/06 for 10 staff. Not all staff have attended training in dealing with challenging or aggressive behaviour. It is very important that the senior staff who will take the lead in any situations that arise attend this training as soon as possible. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The quality outcome area is adequate as there are some strengths but there are areas of particular weakness. This judgment has been made using available evidence including a visit to the service. The manager must apply for registration with the Commission. Finances were found to be incorrect for 2 services users and the annual Gas safety certificate could not be located. These areas require attention to ensure the ongoing well being of service users. EVIDENCE: The home has employed a new manager. The manager must apply for registration with the Commission. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 21 Since the last inspection there have been a lot of changes for the benefit of the services users and the home is now being run in a more organised and open manner. A quality assurance audit should now take place. Questionnaires should be sent to service users who are able to make a comment on the operation of the home, relatives and health professionals. Once this information is returned an analysis of this should be made and the findings added to the Service Users Guide. Service users finances were inspected. It was observed that for the majority of service users the recording and money held in safekeeping was correct. However for one service user the record identified a chiropodist charge of £13.00 but the amount had not been deducted from the cash held. This is poor practice. For a further service user’s money, the record identified £62.00 was held but when the cash was counted there was £55.00, £7.00 was missing (this money was counted in the presence of the manager). The hairdresser charges £7.00 therefore it is possible that the money was deducted and not recorded as hairdressing charges taken out. All entries and expenditures must be made on the day of each transaction. If there is a mistake, and money is missing then the home must refund the £7.00 to the service user. It is recommended that two people check all money held in safekeeping randomly and sign to say that the money has been audited. Staff are now receiving formal written supervision. The home is aware that each staff member must have a minimum of 6 formal supervision sessions for each ‘rolling’ year. The majority of health and safety documentation was completed as required by the regulations, but the Gas safety certificate could not be found. This must be faxed to the Commission. Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 3 x 2 Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) & (2) Requirement Care Plans must identify all the needs of service users and be updated as changes occur. This is a restated requirement from the last inspection. An updated care plan, risk assessment and intervention plan must be drawn up for one service user who shows challenging behaviour. Medication must be appropriately documented and signed at the time of administration. Information of wishes at the time of death for all service users should be documented in the care plan. Each staff member employed must have 2 written references. (photocopies to be sent to the Commission for 2 staff identified). The complete employment file that could not be found at the time of the inspection for the staff member identified should to be photocopied and provided to the Commission. All senior staff must undertake
DS0000062659.V297965.R01.S.doc Timescale for action 30/07/06 2 OP7 14(2)(b) & 13(4) (c) 13(2) 15 (1) 20/06/06 3 4 OP9 OP11 12/06/06 30/07/06 5 OP29 19 Schedule 2 1-8 19 Schedule 2 1-8 12/06/06 6 OP29 12/06/06 7 OP30 18(1)(c) 30/08/06
Page 24 Barleycroft Care Home Ltd. Version 5.2 (i) 8 9 OP31 OP33 9 24(1)(a)& (b) 10 11 OP35 OP38 17(2) schedule 4 9(a) 13(4)(c) training in dealing with challenging behaviour/aggression. The manager must apply for registration with the Commission. A quality assurance audit should be undertaken and the findings from service users, relatives and health professionals analysed and added to the Service Users Guide. All money spent on behalf of the service users should be correct at all times. A copy of the annual Gas safety certificate must be sent to the Commission. 30/06/06 30/09/06 12/06/06 12/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Barleycroft Care Home Ltd. DS0000062659.V297965.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford 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. DS0000062659.V297965.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
