Inspection on 06/09/06 for Barnfield Manor Care Home

This inspection was carried out on 6th September 2006.

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

Barnfield Manor Care Home 28/07/09

Barnfield Manor Care Home 07/05/09

Barnfield Manor Care Home 03/06/08

Barnfield Manor Care Home 14/11/07

Barnfield Manor Care Home 09/01/07

Barnfield Manor Care Home 09/05/06

Barnfield Manor Care Home 22/02/06

Barnfield Manor Care Home 05/10/05

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

CARE HOMES FOR OLDER PEOPLE Barnfield Manor Care Home Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH Lead Inspector Susan Richards Key Unannounced Inspection 6th September 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 Manor Care Home DS0000064197.V304414.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 Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barnfield Manor Care Home Address Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH 01246 855899 01246 852953 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) Hallmark Healthcare (Holmewood) Ltd Vacant Care Home 39 Category(ies) of Dementia (39) registration, with number of places Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Barnfield Manor Care Home provides personal care and support for up to 40 older persons with dementia delivered by a team of care and hotel services staff currently led by an acting manager. The home comprises three separate areas of accommodation for service users, each having its own dedicated facilities, including lounge/dining rooms, bathrooms and toilets. Adequate car parking is provided, together with accessible and secure dedicated garden areas. There is a separate single storey building located within the grounds, which provides a central laundry and staff facilities. The home is located in the village of Holmewood, close to shops, a post office and local amenities. It is on a direct bus route to Chesterfield and within a short distance of Junction 29 of the M1 motorway. There is a passenger lift and emergency call system provided, together with handrails to corridors and grab rails to toilets. Bedrooms provide a majority of single room accommodation with many having en suite facility and there are additional communal bathing and toilet facilities provided. At the time of the inspection there were 18 residents accommodated. The range of fees charged by the home, are detailed within the home’s service user guide/statement of purpose. For residents who receive assistance with funding via Derbyshire County Council Social Services Department, fees are in accordance individual purchasing contracts between Social Services and the home and are detailed within the written terms and conditions provided by the home to the resident. For residents who are privately funded details of fees are set out within individually written contracts between the home and resident. Written information provided by the home as at 24 August 2006 details its range of fees charged as follows: Standard fees charged are £289.70 - £316.80 per week. Private fees charged are £315.00 - £340.00 per week. There are additional charges for hairdressing, chiropody and newspapers as per Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 5 item. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the second key inspection for this service for the inspection year April 2006-March 2007. During the inspection case tracking was used as part of the methodology. This involves the random selection of three residents, whose care plans and associated records were examined. Discussions were also held about with relatives and representatives regarding their care and observations were made in respect of the organisation of their care and its delivery and also their private and communal space was inspected. At the time of this inspection 18 residents were accommodated. The Inspector was unable to engage in any meaningful discussion with residents due to their given mental capacities. There is no registered manager for the home (since early 2006). An acting manager has been in post since the beginning of May 2006. What the service does well: What has improved since the last inspection? What they could do better: Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 7 I number of regulations have been persistently breached. This has resulted in a management review of the home. Action, which is required to be taken, has been set out in writing to the registered provider. Failure to make the required improvements within timescales identified will result in enforcement action. 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 Manor Care Home DS0000064197.V304414.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 Manor Care Home DS0000064197.V304414.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): 3&4 Residents’ needs were not always fully accounted for or effectively met. Quality outcome in this area is poor. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: Case tracking was undertaken in respect of three residents accommodated, including the most recent admission to the home. The written needs assessment information recorded for each of those residents was examined. The recording format used was in accordance with a recognised assessment model, although information recorded was variable, with omissions in recording, including individual’s social, communication and emotional needs ranging from being well documented to little or no information. Standardised risk assessment scoring tools were used to determine personal safety and individual risk in accordance with recognised practise, which had periodic reviews recorded, although records of reviews were not always dated and were not always carried out at monthly intervals. The accuracy of their Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 10 completion was also variable and information recorded was not always in accordance with that detailed in individual’s overall needs assessments or their current presentation. All of the residents’ case-tracked were privately funded. The pre-admission assessment information for the resident most recently admitted to the home was examined. This was only partially completed. Discussions were held with an advocate of one of the residents’ case tracked who felt their needs were being well met. Discussions were also held with three other relatives in respect of residents care needs and how these were met and also staff on duty, together with a visiting district nurse. Whilst it was felt that there had been some improvements made in respect of approaches to care delivery since the previous inspection in May 2006, significant concerns were raised by these in respect of residents safety, staffing levels and staff training and skill mix. The Inspector also observed some aspects of care delivery to residents. Staff was working hard to meet residents needs within the resources available to them. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 & 10 Significant aspects of residents’ health, personal and social care needs were not always properly identified within written care plans, their dignity was not always effectively promoted and their health care needs were not being effectively met. Staffs’ practises were poor and unsafe in respect of the management, administration and storage of residents’ medicines. Quality outcome in this area is poor. This judgment has been made using evidence available, including a site visit to the home. EVIDENCE: The care plans of residents’ case tracked were examined. Some aspects of individual’s care plans were well recorded. However, there were inconsistencies and omissions of recording in relation to some individual’s risk assessment information, their individual care plans and changes in their needs, particularly in relation to risk of falls, nutritional risk and pressure ulcer risk. Monthly review dates of care plans were recorded as having taken place. The use of person centred care planning in respect of individual’s social, emotional and communication requirements were considerably lacking. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 12 The manager and staff were not aware of the provision of any policy guidance in respect of falls prevention in the home. A significant number of falls, including a number of serious injuries resulting from these were recorded in the care records of those residents case tracked. Accident records in respect of falls were also examined and concerns were raised with the acting manager regarding the reasons for these and their number and frequency of these. Relatives/representatives spoken with also raised concerns in respect of these. The personal hygiene needs of residents were generally well recorded, with the exception of foot care and oral care. The outcome of a recent complaint in respect of the care of a service user via Derbyshire County Council’s Safeguarding Adults procedures identified poor foot care and a failure to refer to appropriate healthcare services (district nurse) in respect of pressure ulcer risk and care. The manager advised that action was being taken to review each residents’ foot care needs. The arrangements for the management and administration of medicines for those service users case tracked were examined. At the previous inspection for this service serious concerns were raised separately in writing with the registered provided regarding identified poor/unsafe practise in the administration and recording and storage of medicines, which had been raised as a requirement in the inspection report of 05 October 2005. This was still not complied with at this inspection. The acting manager advised that all staff responsible for administering medicines had undertaken medicines training, although documentary evidence of this was not provided. The acting manager advised that further training was being organised for those staff. Of the nine care staff listed as responsible for administering medicines, only four specimen signatures were recorded. During the inspection a discussions were held between the district nurse and acting manager regarding the home’s failure to obtain a prescribed medicine for a resident in accordance with the written prescription. Medicines requiring storage in a refrigerator were not properly or safely stored. The manager advised that a dedicated medicines refrigerator had been ordered. The Inspector also held discussions with the district nurse regarding communication and care practises in the home. Staff was observed to be respectful in their approaches to residents during the inspection, although skill deficits were evident in respect of recognised approaches to dementia care and the promotion of residents dignity. Overall relatives and representatives gave positive feedback in relation to staff’s manner and approaches with residents, but felt that staff skills were variable. Issues were raised by them in respect of a number of omissions in personal care related to individual’s dignity. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 13 Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 & 15 Residents receive a nutritious diet. Residents’ social, religious and recreational interests were not effectively promoted in accordance with their known lifestyles and given capacities. Quality outcome in this area is adequate. This judgment has been made using evidence available, including a site visit to the home. EVIDENCE: Individuals preferred routines were not fully recorded for those residents case tracked, although some aspects of their known preferences were accommodated. Discussions was held with staff regarding routines in the home, for example going to bed and getting up times. For those residents who needed two to assist to bed and to get up their routines/times were determined by staff availability. There is a vacancy for an activities co-ordinator. This had been temporarily filled for a short time period following the previous inspection and staff and relatives gave positive feedback regarding improvements during that time in respect of social care and activities provision for residents. Care staff said that they tried to spend time with residents whenever possible in terms of providing some occupation and leisure activities although staffing levels impacted Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 15 considerably on the time available. Individual care plans were not in place in relation to social, occupational and leisure activities for residents and staffing levels did not permit access to the community for residents. There was no record of individual activities in the care records of those residents case tracked. There were opportunities for gentle exercise for residents by way of an outside group who attend the home on a monthly basis and for residents to listen to music. Visiting to the home is open. There were suitable arrangements in place for those residents case tracked in respect of the management of their financial affairs given their individual mental capacities. Menus were provided, which have been reviewed since the previous inspection. These provided a nutritious and wholesome diet. Residents’ known likes and dislikes were accounted for. The organisation and serving of lunch for residents was observed. Food served was suitably presented and tables attractively set. There was however, insufficient dining space/furniture to enable all residents to sit at the dining tables should they wish. A significant number had their meals from their own small individual tables placed in front of their lounge chairs. Residents were not hurried and assistance was given to those who required although this took some time due to staff availability. Some concerns were raised regarding inappropriate eating utensils and drinking vessels sometimes being provided for some residents, which did not promote their independence. Specific needs in respect of these were not identified in their care records. Relatives and advocates spoken with expressed the view that the quality and quantity of food provided was good. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Concerns and complaints were not always recorded properly and were not always effectively dealt with formally. Operational systems, including staffing arrangements undermined the promotion of safe and best practise in respect of the protection of vulnerable adults from abuse. Quality outcome in this area is adequate. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: There is a complaints procedure in place for the home. The complaints record was examined, which detailed one complaint including outcomes and action taken. CSCI is advised of three other formal complaints since December 2005. There were no records of these provided by the home. Discussions were also held with relatives regarding concerns/complaints. There is a written policy and procedure in place in the home in respect of safeguarding adults, not all staff spoken with was conversant with this. A training matrix devised by the acting manager detailed that less that half of care staff had received abuse awareness training and dealing with aggression. Two of the residents case tracked had aggression identified as a care need in the individual’s recorded needs assessment information. However, the type and frequency of aggression was not identified and their written care plans in relation to this need were insufficient. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 17 Discussions were held with staff regarding approaches to managing wandering behaviours and aggression. Operational care and management systems were not clear or consistent in terms of managing these. Relatives also expressed some concerns in relation to this. The arrangements for the management and handling of residents monies was discussed with the acting manager and administrator and records and related policies and procedures examined, which were satisfactory. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 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 the following standard(s): 19, 24, 25 & 26 Residents live in a safe and well-maintained environment, which is furnished and decorated to a good standard. Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: The private and communal areas accessed by residents’ case tracked were examined. These areas, together with the rest of the home have been subject to a total upgrading and renewal of fabric the building, which are conditions of the home’s registration. The acting manager advised that this is now completed, which is in accordance with the extended timescale agreed with the provider. The conditions therefore, no longer apply and will be removed. Visitors to the home and staff were very positive about the changes in the environment, which it was felt are a great benefit to residents accommodated. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 19 All areas seen were clean and odour free and furnished and decorated to a high standard. The fire officer last visited the home in December, where all matters appertaining to fire precaution were reported to be satisfactory. At the previous inspection of this service, a requirement was made in respect of ensuring suitable moving and handling equipment is provided in accordance with residents needs. There has been no change to the equipment provided. The acting manager advised that an audit has been undertaken in accordance with residents assessed moving and handling needs and that no additional equipment is required at this time. The laundry was not inspected on this occasion. At the previous inspection for this service a requirement was made in respect of infection control procedures carried out by staff with respect to the handling of linen. During this inspection poor staff practise was observed in respect of this, which were not in accordance with the home’s infection control procedures provided or recognised practise. (See also Staffing section of this report). Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 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 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 Residents needs were not effectively met by the numbers and skill mix of staff, staff were not being effectively trained and inducted and residents were not protected by the home’s recruitment practises. Quality outcome in this area is poor. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: The arrangements for staffing provision in the home were discussed with the acting manager, staff and relatives/representatives and the arrangements for staff recruitment, induction and training were also discussed and records examined in respect of these. Observations were also made during the inspection in respect of staff provision and deployment and the care of residents. Serious concerns have been raised with the registered provider at previous inspections for this service (February and May 2006) regarding insufficient care and hotel services staffing. A requirement was also made at the previous inspection regarding the lack of staff training, including induction training. The registered provider responded with written details of action to be taken/improvement plans in respect of these. These were not complied with at this inspection. With the exception of the current working rotas, previous staff duty rotas were not being retained. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 21 The acting manager was not clear regarding the number of staff having achieved at least NVQ level 2. Neither she, nor any of the care staff on duty had achieved this. A total of eight staff had commenced employment in the home since the previous inspection for this service in May 2006, including four care staff and four hotel services staff (one of the latter had left before this inspection). Information provided by the manager on the pre-inspection questionnaire gave no details of confirmed CRB checks being confirmed with the exception of one. Staff records were examined for four of those care staff. Unsatisfactory records and information were provided in respect of their fitness to work in the home. Serious concerns were raised with the registered provider following the previous inspection for this service in relation to staff recruitment practises/staff records. These were not complied with on this occasion. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 22 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, 37 & 38 Management and administration arrangements are unsatisfactory and residents’ best interests, health and welfare is not always effectively promoted or protected. Quality outcome in this area is poor. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: There is no registered manager in post in the home since early 2006. At the previous inspection for this service a requirement was made to ensure the development of effective quality assurance and quality monitoring systems, including seeking views of service users/representatives. The acting manager advised that a system was being introduced being in initial stages and that some systems audits were being undertaken. These had commenced in three areas. Meetings had commenced with relatives and representatives of Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 23 residents. Progress with the introduction of this system will be monitored at the next inspection. Details of the homes operational policies were provided in the pre-inspection questionnaire. A number were sampled during this inspection. The arrangements for the management and handling of resident’ monies are commented on under the Complaints and Protection section of this report. These were satisfactory. At the previous inspection of this service in May 2006 a requirement was made to ensure that all staff received individual formal supervision. This had commenced and was being rolled out to all staff. During the inspection a number of records, which are required to be kept in the home were examined. These are identified under the relevant sections of this report. Records were not always being kept as required or properly maintained. Comments made under the staffing section of this report, in respect of staff training and induction, include that relating to safe working practises. During discussions with staff and relatives a number of concerns were raised in respect of residents wandering behaviours and a potential environmental risk to residents as a result of this. This related to the area of corridor leading from the ground floor rear unit entrance to the lounge and particularly around the lift area. Accident forms examined indicated that there are a significant number of accidents to residents in this area. There were no environmental risk assessments in place for residents in respect of their wandering behaviours. The Inspector observed cleaning fluids were not stored safely or correctly during this inspection. This was raised in writing during the inspection as a serious concern detailing action to be taken by way of an immediate requirement. Written details of the most recent service inspection of the hot and cold water systems, including the arrangements for water temperature checks from bathing outlets and also the electrical hardwiring system were not provided in the pre-inspection questionnaire. This was discussed with the maintenance person employed in the home. Details of the last service inspection of hoists were not provided within the preinspection questionnaire. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 24 Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 25 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 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X 3 3 3 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X 1 1 Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Residents care plans must clearly detail how their needs are to be met in respect of their health and welfare. It must be ensured that arrangements are made for residents to receive, wherever necessary treatment, advice and other services from any health care professional. Suitable arrangements must be made for the recording, handling, safekeeping and safe administration of medicines in the home. With regard to the size of the home, the statement of purpose and the number and needs of residents, there must be at all times suitably qualified, competent and experienced staff working at the home in such numbers as are appropriate for the health and welfare of residents. A person must not be employed to work at the care home unless they are fit to do so and all information and documents have DS0000064197.V304414.R01.S.doc Timescale for action 31/10/06 2. OP8 13 31/10/06 3. OP9 13 31/10/06 4. OP27 18 31/10/06 5. OP29 19 31/10/06 Barnfield Manor Care Home Version 5.2 Page 27 6. OP30 18 7. OP37 17 8. OP38 13 9. OP38 13 been obtained in respect of that person as specified in paragraph 1 to 7 of Schedule 2. All persons who work at the care home must receive training appropriate to the work they are to perform (including induction training). Records must be kept and maintained in accordance with Schedules 2, 3 and 4 of the Care Homes Regulations 2001. Unnecessary risks to the health and safety of residents must be identified and so far as possible eliminated by ensuring the maintenance of systems and equipment and the safe storage of substances, which may be hazardous to health. Unnecessary risks to the health and safety of residents must be identified and so far as possible eliminated. In this instance environmental risks assessment undertaken and recorded in accordance with individuals’ wandering behaviours. 31/10/06 31/10/06 06/09/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 Good Practice Recommendations Residents’ needs assessment information must include all items detailed under NMS 3.3, Care Homes for Older Persons. Residents’ care plans should be further developed to be person centred in their format and to reflect individual’s known preferences, likes and dislikes and daily living routines, in respect of their social, emotional, communication and personal care needs. DS0000064197.V304414.R01.S.doc Version 5.2 Page 28 OP7 Barnfield Manor Care Home 3. 4. 5. OP8 OP10 OP12 6. OP16 A falls prevention policy strategy should be developed and individual’s care plans in accordance with this, based on recognised practise and individual’s risk assessed needs. Residents’ dignity should be effectively promoted. The arrangements to enable residents to engage in social, recreational and community activities should be developed in accordance with their known preferences and dementia care needs. Care approaches in respect of dealing with agitation, aggression and managing wandering behaviours should be developed in accordance with evidence based dementia care practise. Barnfield Manor Care Home DS0000064197.V304414.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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