CARE HOMES FOR OLDER PEOPLE
Barnfield Barnfield 24 Upfield Horley Surrey RH6 7LA Lead Inspector
Megan McHugh Key Unannounced Inspection 29th 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 Barnfield DS0000013562.V302003.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. Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Barnfield Address Barnfield 24 Upfield Horley Surrey RH6 7LA 01293 786798 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) sharon.blackwell@anchor.org Anchor Trust Mr Ayobami Olaonipekun Adeluola Care Home 63 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (21), Old age, not falling within any other category (63), Physical disability over 65 years of age (17), Sensory Impairment over 65 years of age (17) Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Up to 21 of the older people accommodated may have a mental disorder and/or dementia. Up to 17 of the older people accommodated may have a sensory impairment and/or physical disability 14th November 2005 Date of last inspection Brief Description of the Service: Barnfield Residential Care Home is owned and managed by Anchor Trust. It is a substantial detached property that has been purpose built to provide accommodation for sixty-three service users. The home is located in a quiet residential area of Upfield in Horley. Access to shops, church, public transport and other local services are within easy reach. The accommodation for service users is provided on two floors, in seven separate units. Each unit has a separate name; each has a lounge, dining room and kitchenette. All bedrooms are single and twelve of them have en suite facilities. There is a passenger lift accessing all floors. In addition to this there is a large communal lounge that doubles up as a day centre. The home is located in substantial grounds that incorporate a garden and a sitting area. The home has a parking area at the front for a number of cars and there is additional parking space on the road outside. Fee range is from £600.00 per week for personal care. Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by Meg McHugh, Regulation Inspector for the service and Geraldine Yates, Pharmacist Inspector. The inspection was undertaken over a period of six and a half hours for the regulation inspector and two and a half hours for the pharmacist inspector. This was a key inspection in the Commission for Social Care Inspection (CSCI) year 2006 to 2007. The registered manager was not present during the inspection as he is on sick leave. The home is being managed by an acting manager who has been previously registered with the Commission. She is being assisted by the home’s deputy manager. They were both present during the inspection process. Two relatives, eight service users and one member of staff had in depth discussions and a number of service users and four members of staff had short conversations (in passing) with the inspector. Records were sampled and a tour of the premises was undertaken during the inspection process. The Commission would like to thank the staff and service users for their hospitality and cooperation throughout the inspection process. What the service does well:
The service users appeared comfortable and were able to express that they were happy with the care they received. There were a lot of activities on offer and staff were actively working with the service users to encourage them to participate in activities. The environment was clean and tidy. The home has a good rolling repair and redecoration programme in place to keep the premises well maintained. The home was running smoothly under the leadership of the acting manager and deputy manager Most of the records sampled were maintained clearly and in an organised manner. Staff were friendly and courteous to the service users. Service users stated that the staff are kind, respect their privacy, one stated that she was really happy and the staff are nice. Another service user stated that she couldn’t ask for more really. A service user stated that that she likes having her independence and that the home respects this. A number of service users and relatives stated that they were aware of the acting manager’s role and that they had met her and that she had made an effort to Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 6 get to know all the service users in the home. This was a positive approach to managing the home. What has improved since the last inspection? What they could do better:
The home has an Independent Lifestyle Agreement (ILA) document in place that serves as the care plan. Of the four plans sampled in depth, only one was completed fully. The other three had many gaps where information had not been filled in, although it was clear that staff were aware of certain information, this had not been documented. All service users must have completed plans in place within a reasonable time following admission to the home. None of the plans sampled were reviewed on a monthly basis as required and this too was made a requirement. The Pharmacist Inspector inspected the areas that fell under the medication and found that not all of the staff had received the training required to do all of the tasks they were being asked to do. Temperature records were not being kept for the medication refrigerator which means that the quality of the medications kept in it cannot be guaranteed. The records showed that one medicine had been out of stock for one service user for three days, four medicines had been out of stock for a second service user for five days and that another medicine had not been available since lunchtime of 26th June
Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 7 2006 for a third person. If medication is not available in the home the health and welfare of service users could be put at risk. Some service users hold and administer some of their own medications but not all had the risk of this assessed, which could be putting them or others at unnecessary risk. Requirements were made in relation to all these areas. The home has some risk assessments in place and as part of the ILA system, the risk is highlighted and there is an area for action plans to be written to manage identified risks. However, not all risks to the service user’s safety had been identified and documented. Staff discussed actions that they taken to ensure service users are safe and for one service user in particular, staff had many practices in place to keep her safe. None of these were documented and therefore no proof could be found that these actions were being taken. All risks to each service user must be identified and documented plans must be in place and kept under review. This includes any financial risks for service users who hold their own money. The home needs to implement a training plan for staff to achieve their National Vocational Qualification (NVQ) targets of 50 of staff with the level 2 qualification or above. It is acknowledged that a number of staff, including those who had obtained a qualification, have resigned recently, however area needs to be prioritised and an action plan must be developed. 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. Barnfield DS0000013562.V302003.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 Barnfield DS0000013562.V302003.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): 1 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed prior to admission in to the home to ensure that the home is able to meet their needs. The home does not provide intermediate care. EVIDENCE: The Four files that were sampled in depth all contained pre-admission assessments by the local county council and a short additional assessment from the home. The manager stated that they do not complete a detailed assessment, as the county councils assessment is very detailed. A copy of the homes full assessment was seen and was satisfactory. One file sampled was for a respite client and this also contained the required information. Barnfield DS0000013562.V302003.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Individual Lifestyle Agreements (ILA) documents must be completed in full to ensure that the service user’s health, personal and social needs are known and can be met. These plans need to be kept under monthly review to ensure service users needs are being met. Risk assessments processes must be strengthened to keep service users safe and for staff to be aware of these risks. Medication administration was satisfactory. Areas of training for staff and risk assessing service users who self administer medication must improve. Service users rights and privacy was respected. EVIDENCE: Four care plans were case tracked and a number of other care plans were viewed during the process. The home uses an Individual Lifestyle agreement or ILA system for their care plans and this was seen to be holistic in nature and included physical, mental, emotional, social and personal care needs. This was positive to see. However only one of the ILAs were completed fully, the others were not completed and large areas of these documents had information missing. For example: the religious needs of a service user or the dietary needs.
Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 11 None of the units care plans sampled were reviewed on a monthly basis. The home has risk assessments in place for some identified risks but not all. One example was for a lady who is able to take the bus into town for shopping and has been taught by staff how to get around the local area. This was very pleasing and indicated that her rights were being upheld. However there was no risk assessment in place for is she became lost or if the service user was attacked. This service user ‘loses’ money frequently and again no action was in place to help prevent this from happening. This was discussed at length with the acting manager, deputy manager and bursar. It was pleasing to note that many ILAs were signed by the service users and during the course of the day service users informed the inspector of their care plans and that they helped develop these when they were admitted. Service users health care needs are met. All service users were registered with a GP surgery and some informed the inspector that they still attend their old GP surgery that they attended prior to moving into Barnfield. This was pleasing to hear. The home is supported by the district nurses and there was evidence in service users files of visits to or from the optician, dentist, audiologist, dietician and physiotherapist. Medication storage and records were sampled on three of the seven units and in the central medication storage room. Medication is handled and administered by staff who work to written procedures which describe all of the tasks staff may be expected to undertake when handling medication. However not all of the staff had received the training required to do all of the tasks they were being asked to do. Most service users had their medication given to them by the care staff with clear records being made of all medicines coming into the home and of the medication given to service users plus clear reasons if medication was not given. Some service users did hold and administer some of their own medications but not all had the risk of this assessed, which could be putting them or other service users at unnecessary risk. The records showed that one medicine had been out of stock for one service user for three days, four medicines had been out of stock for a second service user for five days and that another medicine had not been available since lunchtime of 26th June 2006 for a third person. If medication is not available in the home the health and welfare of service users could be put at risk. Medication was stored securely for the protection of the service users. Medication cupboards and trolleys were clean and orderly with the keys being held by the care staff. Temperature records were not being kept for the medication refrigerator, which means that the quality of the medications kept in it cannot be guaranteed. Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 12 The care practice observed during the inspection process showed that service users privacy is respected. The staff were overheard talking respectfully with service users and many service users stated that the staff are kind and respect their wishes. Staff were observed knocking on doors and it was noted in the ILAs what name the service user prefers to called. Barnfield DS0000013562.V302003.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities provided were satisfactory and offered a good range of activities to suit as many service users as possible. Visitors are welcome in the home at anytime and the meals provided met service users needs. Service users exercise choice and control over their lives. EVIDENCE: The activities lady was on duty on the day of the inspection and staff provide some activities on their units. A copy of the programme of activities was provided and this showed a varied range of activities were provided to suit a wide range of service users likes and needs. The home has a large day room on the ground floor where many of the activities take place. Staff stated they try to provide some activities on their units for service users but many do not wish to participate. Service users spoken with stated that activities are provided and that many are very good. A service user stated that they sometimes take part but not always out of choice. The manager stated that the activities lady keeps records of who attends what activities and that she visits those service users who do not take part in activities in their bedrooms. In
Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 14 most of the units in the afternoon of the inspection, the service users were watching Wimbledon. Many service users talked to the inspector about their visitors and stated that they can visit at any time. Some visitors were seen in the home and two were spoken with. Service users talked about going into town for shopping or for a walk with staff in the garden. A service user talked to the inspector about how staff have taught her how to catch the bus into Reigate and Redhill and then she is able to go shopping and get out and about. She showed me her bus pass and the card that has her name and the address and telephone number of the home on it in case she gets lost or confused. The same service user talked to the inspector about being a Jehovah Witness and that she attends her place of worship regularly. It was noted in the ILA that service users religious requirements could be recorded although these were not done. Service users discussed choice and how they still have control over their lives even though they require assistance with some activities. A copy of the menus provided was given to the inspector. These are varied and offer choice of meals. Comments from service users in relation to meals were positive. The kitchen was inspected and no issues were seen. The home had plenty of fresh fruit and vegetables in stock. The manager stated that the chef only uses frozen vegetables when no fresh ones are available. All food is cooked on site and fresh ingredients are used as much as possible. Barnfield DS0000013562.V302003.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their concerns are listened to, taken seriously and acted upon. The service users are safeguarded against abuse. EVIDENCE: The homes complaints log was sampled and contained information about complaints made directly to the home and action that was taken by the home. The manager talked about the homes complaints procedure and evidence showed that this was followed. A service user stated that they knew who they would complain to should they need to do so and they stated that the homes service user guide was in their bedroom and this contained information they need about complaints. Both relatives spoken to during the course of the inspection stated that they were aware of who they should talk to if they had a complaint. Records sampled indicated that staff have had training in safeguarding vulnerable adults in their rights and responsibilities training in their induction. Other staff training records indicated that some staff have had further training in this area, including the manager. Staff stated that they were aware that they must report any incidents they are concerned about and discussed the types of abuse that can occur. The home has a service procedure and a copy of
Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 16 the local multi-agencys procedures for protecting vulnerable adults. During a recent incident the home followed the correct steps for reporting an incident. Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 17 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained, kept in a good condition, was clean and hygienic. EVIDENCE: The home comprises of seven (7) units over two floors, each unit with its own lounge and dining room area. There is a large day room on the ground floor for activities and a small seating area on the ground and first floor. The garden is secure and accessible from the ground floor. A copy of the survey which highlights areas of redecoration, carpet replacement and furniture replacement was provided to evidence the planned work for the year in the home. All areas of the home were in a satisfactory condition and there was evidence of this rolling programme in place. The fire escape door, leading onto one of the ground floor units, handle was very loose and this could lead to a serious problem should it coma off. This was discussed
Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 18 with the acting manager who showed evidence of contact with the responsible company to act immediately to fix this. However the home has had no response from this company and have therefore requested another company to fix this door handle. Evidence showed that the company was due in the home on the 30th June 2006, the day after this site visit/inspection. The manager has since contacted the Commission to confirm the door handle has been fixed and there is no longer any risk to staff or service users in relation to that fire escape. The home was clean and good infection control care practice was observed. COSHH (Control Of Substances Hazardous to Health) cupboards were locked on each unit and no items in this category were seen to be unattended in the home. Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is staffed in order to meet service users needs. Staff training is satisfactory and the home is working towards meeting their targets of 50 staff with an NVQ qualification. Recruitment procedures were sound and protected service users. EVIDENCE: The staffing levels were satisfactory on the day of the inspection. The manager stated that there are 8 care staff on duty with a senior care officer during the waking day (7:30- 20.00). This means that each unit is staffed with one carer to float between units. The manager stated that they are nearly fully recruited. Service users stated that they were well looked after, get all the attention they need, staff are kind, we are treated very well. These indicated that the home is not understaffed and that service users are treated well. The home has a rolling NVQ programme in place and staff discussed a workshop that was booked in the near future for those staff who wanted to start their NVQ training. The home has recently lost a number of staff members and therefore the percentage of staff with a qualification has reduced greatly. An action plan for how the home plans to meet their 50 targets is requested and this will be followed up at the next inspection.
Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 20 Staff discussed training with the inspector and informed her what training they had received, this included the mandatory training in fire safety, moving & handling, health & safety, 1st Aid, food hygiene and protection form abuse. Other training provided included medication training, and this is discussed more under Standard 9 relating to medication. The staff require dementia care training and the acting manager stated that Anchor is rolling out a 5 day training programme on dementia and training dates have been confirmed for July 2006. Four staff files were sampled in detail and these all contained the required information of proof of identity, CRBs, two references. Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 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 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team was sound and the views of service users was actively sought. There was a concern about a service user’s risk assessment in relation to financial transactions in the home. No issues were raised about the health, welfare and safety of service users. EVIDENCE: The home’s manager is away on sick leave following an accident while visiting overseas. He has recently been approved as the registered manager of this service with the Commission. An acting manager is in place to cover his absence and this manager has been a registered manager in another of the anchor homes. The deputy manager is assisting the acting manager with the running of the home and this appears to be working well. A service user stated that she liked the new manager who visits her and talks to her most days.
Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 22 Many service users were aware of the manager acting in the managers place and the reason for this. Staff had a good relationship with the acting manager and appeared to work well as a team. The manager stated that the home welcomes feedback from all the visitors and the residents. There are consistent efforts from both the management and the care staff to encourage residents to take part in the running of the home. The monthly residents and relatives meeting was held on a monthly basis and posters were seen in all units advertising this. The minutes of the meeting held in May were also seen on a notice board. There are opportunities offered for one to one discussions with the manager. The deputy manager stated the home’s surveys had been made available to service users and relatives to complete although this was an ongoing process. One relative stated that the communication between the home and herself in relation to the care of her relative was very good. The home has recently completed a quality assurance exercise in relation to staff in the home coming from many different backgrounds and countries and the effect this has on the care and understanding of service users. An action plan is being put in place to address the issues raised by the survey. The bursar was able to discuss the homes financial records and informed the inspector how the individual service users records are maintained. The homes policy and procedures were adhered to strictly in dealing with any finances. One area of concern was discussed in detail about a service user who requests money from her personal monies held by the home and then appears to lose this money. No risk assessment was in place and discussions with the service user and their representatives were held but no record was kept of these discussions. A requirement has been made under Standard 7 in relation to risk assessments and this will be incorporated there. There are a number of good health and safety policies and procedures in the home. The staff received training in all aspects of health and safety with regular yearly updates. There is a maintenance man available to take care of any day-to-day repairs and general checks on premises and equipment and contractors are also used. Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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) Requirement Timescale for action 13/07/06 2. 3. OP7 OP7 4. OP9 The registered person must ensure that all service users have a comprehensive plan in place that sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the service user’s needs are met. 15(2)(b) All care plans must have documented evidence of monthly reviews 13(4)(b)(c The registered person must ) ensure that all activities and any unnecessary risks to the health or safety of service users are identified and as far as possible eliminated. Documented evidence in the form of risk assessments must be developed and held on file for any service user who may be at risk. This includes financial risk assessments for service users who ‘withdraw’ money from their personal accounts held by the home. 18(1)(c)(i Staff must receive training ) appropriate to the work they are to perform, in particular relation
DS0000013562.V302003.R01.S.doc 27/07/06 13/07/06 27/07/06 Barnfield Version 5.2 Page 25 5. OP9 12(1)(a) 6. OP9 13.2 7. OP9 13.2 13(4)(b) 18(1)(a) 8 OP28 to medication training. Service users must not be left without access to medication prescribed for them by their GP. Systems must be put in place by the provider to ensure that medication is ordered and received at appropriate times to ensure it is always available to the service users. A thermometer must be kept in the medication refrigerator and daily temperature records made to ensure that it is operating within the correct range of 2 to 8 degrees centigrade and that the quality of the medication held in it can be assured. A documented risk assessment must be in place for all service users who undertake to selfadminister their own medication. The registered person must provide a plan informing the Commission how the home intends to meet the 50 target of staff working in the home with a National Vocational Qualification (NVQ) of at least a level 2. 27/07/06 27/07/06 29/06/06 27/07/06 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 Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Barnfield DS0000013562.V302003.R01.S.doc Version 5.2 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. 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!
