Inspection on 09/01/07 for Barnfield Manor Care Home

This inspection was carried out on 9th January 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 06/09/06

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 Unannounced Inspection 09th January 2007 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.V324586.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.V324586.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.V324586.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 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. A central garden is provided and a patio area to the rear of the home together with car parking to the front. 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 item. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 5 Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the third key inspection of this service for the inspection year 2006-07. At the time of the inspection there were 18 service users accommodated. Case tracking was used as part of the methodology for the inspection. This involves the random sampling of a small number of service users (in this instance three), whose care and service provision is more closely examined. Discussions were held with them/their representatives in accordance with individuals’ given capacities and their care and associated records examined. What the service does well: What has improved since the last inspection? Since the last key inspection improvements in the arrangements for the management and administration of the home have resulted in the following: Service users health, personal and social care needs are more effectively accounted for and met in accordance with their risk assessed needs and their dignity better promoted. The revised arrangements for the management and administration of service users medicines better promote recognised and safe practise. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 7 The arrangements to enable service users to engage in social, recreational and leisure activities has improved considerably with more account taken of their known lifestyle preferences and given capacities. There is considerable improvement in the arrangements for staff recruitment, deployment, induction and training. Management and administrative improvements now better promote and protect service users best interests and their health and welfare. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 8 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 9 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.V324586.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are suitably assessed and reasonably well accounted for. EVIDENCE: The recorded needs assessment information for the three service users case tracked, were examined. There were noted improvements in the recording of these since the previous key inspection of this service in September 2006. They were comprehensive and holistic, accounting for all aspects of individual needs, and included pre-admission assessment information. A revised model of needs assessment was being introduced, which is a recognised care model. Individuals’ daily living routines were accounted for, as were personal safety and risk, which were also consistently recorded and reviewed. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 11 The Inspector was unable to hold meaningful discussions with service users about their needs due to their mental capacities. However, discussions with staff and observations of care delivery and routines indicated that they were conversant with the needs of those service users. The Inspector was not able to meet with any relatives or representatives during the course of this site visit as there were none present. The home does not provide for intermediate care. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9 10 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in individual care plan and their health needs are effectively accounted for and met. EVIDENCE: The written care plans of service users’ case tracked were examined and their care discussed with the manager and staff. Care plans were formulated in accordance with service users assessed needs within a clear framework of risk assessment. They were reflective of recognised guidance concerned with the care of older persons, including their dementia care needs. They had regularly recorded reviews with relevant care interventions recorded in accordance with changes in individual’s needs and conditions. Key areas of improvement had been achieved since the previous inspection of this service with regard to individual’s risk assessment, care planning Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 13 information and care interventions in respect of falls, nutritional risk and pressure ulcer risk. Care plans were also more person centred and included individual’s social, emotional and communication needs and care planning interventions in respect of these. Details of service users access to outside health care professional were also better accounted for than at the previous inspection of this service, including for the purposes of routine health care screening and were satisfactory for those service users case tracked. At the previous inspection for this service serious concerns were raised with the registered provider in respect of the system for the management and administration of medicines. Following that inspection a letter was sent to the registered provider highlighting our concerns regarding the persistent breaching of a number of Care Homes Regulations 2001. These included Regulation 9 of those, which requires the registered provider to ensure that suitable arrangements are made for the recording, handling, safekeeping and safe administration of medicines in the home. These were examined during this inspection with particular focus on those service users case tracked and overall were found to be safe and undertaken in accordance with recognised practise, although the A copy of the report from the local PCT pharmacist advisor of 04 January 2006 was provided during the inspection, which was satisfactory, although attention is needed to the CD cupboard and storage facilities require review in the newly appointed medicines room to ensure that sufficient and suitable are provided for medicines awaiting return to pharmacy. The manager advised that these were in hand. There were no service users accommodated who were able to self administer their own medicines due to their given capacities. All staff responsible for medicines handling and administration had undertaken suitable training since the previous inspection of this service. Service users records examined detailed the regular monitoring of service users conditions and their prescribed medicines, together with requests for and medicines reviews by their GP. The acting manager since commencing her post in October 2006 had introduced monthly medicines audits for each service user, which were being effectively undertaken and included mechanisms for medical reviews of individual service users medication where appropriate. Staff were observed to be mindful in their approaches to service users and discussions with them indicated that they were conversant with their needs, including the promotion of their dignity and privacy. Although the inspector was unable to meet with relatives and representatives of service users on the day of the site visit as there were none present, many service users received regular visits from families and friends and their interests were recorded within individual’s care records. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 14 Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 11, 12, 13 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisation and provision of social care, occupation and leisure activities for service users is considerably improved in accordance with their known lifestyle preferences and capacities and service users are provided with a wholesome balanced diet. EVIDENCE: At the previous key inspection of this service there was vacancy for an activities co-ordinator. This was appointed to in November 2006. Since her appointment, the activities co-ordinator had developed and introduced a weekly programme of core activities, which included arts and crafts, baking, reminiscence and gentle exercise sessions, together with a separate ladies and gents session with activities planned in accordance with their preferences. Activities records were kept for each service user. Details of seasonal Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 16 celebrations were provided, both recent and planned for Valentine’s Day and Easter. A specialised canal boat trip was also planned for the spring. There were various fund raising activities organised for the ‘Residents Fund’ and the Activities Co-ordinator advised of plans to provide and develop reminiscence and memory aids for service users, including a memory box. The manager was planning a relatives/service user meeting, which is to be held on a regular basis and had also liaised with Care Aware Advocacy Service and was in the process of negotiating the purchase of their services to enable access to a range of independent advocacy and advisory services for all service users and their families. This also includes the provision of staff advocacy awareness training and the provision of a regular newsletter for service users/their families. Progress with this will be assessed at the next inspection for this service. Visiting to the home is open. Needs assessment information of service users case tracked detailed social and life history profiles, which included likes and dislikes and previous known hobbies and interests. Food menus had been reviewed prior to the last inspection of this service. These remained and provided a nutritious and wholesome diet. The organisation and serving of lunch was observed during the inspection and discussions were held with the cook and care staff serving and assisting service users regarding individual dietary requirements and assistance and choice of menu. This was well organised in the ground floor large dining/lounge area, plenty of space for service users. A choice of menu was provided for each course and tables were attractively set. Service users were assisted in accordance with their needs in a calm and unhurried manner and appeared to enjoy the food provided, which was well presented. The manager advised that the presentation of menus was under review, with a view to providing ‘photo’ menus for service users to aid their understanding and better promote choice, together with simple written information in large print. Progress with this will be assessed at the next inspection of this service. There was a clear system for monitoring and ensuring the nutritional status of each service user, which staff were conversant with in terms of their individual responsibilities. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives know how to complain and there are suitable systems and arrangements in place to promote the protection of service users from abuse. EVIDENCE: There is a complaints procedure in place for the home. Previous discussions held with service users relatives/representatives indicated that they are aware of this and know how to complain. The complaints record was examined at the previous inspection for this service, although not all complaints made had been recorded therein. Since that inspection, there has been one formal written complaint made directly to the registered provider with a copy of that complaint provided to the Commission by the complainant. The Commission is aware that a written acknowledgement has been forwarded to the complainant from the registered provider advising of intended investigation, which is pending an outcome. The acting manager advised that no further complaints had been received by the home to date. A concern raised by a relative was recorded. This detailed Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 18 action taken and was recorded as resolved to the satisfaction of the person who raised this and who did not wish to make a formal complaint. Ninety percent of staff had received training in abuse awareness since the previous inspection, with additional training planned. Staff was conversant with procedures to follow in the event of the suspicion or witnessing of the abuse of any service user. (See also staffing section of this report re staff recruitment procedures/protection of service users). Recorded needs assessment and care planning information for those service users case tracked contained suitable information in respect of the behavioural needs and required interventions for one service user with regard to potential aggression. Staff policy guidance is in place in the home regarding service users monies and financial affairs, which preclude staff involvement in the making or benefiting from service users wills. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, service users live in a safe, comfortable environment. However, the design and layout of the central garden area may be a potential risk to service users and the further development of the environment in consideration with individuals’ dementia/sensory care needs may greater assist in promoting their wellbeing. EVIDENCE: The home has undergone an extensive programme of upgrading and renewal to the fabric of the building. These were previous conditions of the home’s registration, which were evidenced as met at the previous inspection of this service. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 20 An environmental risk assessment had been carried out since the previous inspection and a record of this was provided. This identified various areas, which require attention, although there was no identified action plan in respect of these. The manager advised this was to be carried out in consultation with the estates officer for the company. The layout of the central enclosed garden area for service users is a potential risk in respect of the height of the raised lawn. This was discussed with the manager who agreed that this required attention. At this inspection, the private and communal areas of service users case tracked were examined, together with the home’s laundry facilities. All areas seen were clean and odour free and furnished and decorated to a good standard, although bathrooms were stark and uninviting and did not provide sensory relaxation. This was discussed with the manager who advised that this was to be reviewed. The manager was in the process of developing picture signs and aids to orientation with many key areas signed. This was discussed with her. Progress will be assessed at the next key inspection of this service. Discussions also took place with the staff and manager regarding the central garden area and availability of access and potential risks for service users. The Fire Officer has not inspected the home since December 2005, when all matters appertaining to fire precaution were reported to be satisfactory at that time. The laundry was inspected on this occasion. This was well equipped, with separate rooms for the processing of clean and soiled items. Sluice areas have been cleared, tidied and made accessible since the previous inspection. The manager advised that one mechanical sluice was out of action but that this was being dealt with. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The clear and measurable improvements regarding the arrangements for staff recruitment, deployment, induction and training better promotes service users safety, with the result that their needs are more effectively met. If these areas of improvement are fully completed and sustained this should ensure that service users needs are continually and consistently met by the numbers and skill mix of staff who are trained and competent. EVIDENCE: The arrangements for staffs’ recruitment, deployment, induction and training were discussed with the manager and staff and associated records examined. At previous inspections of this service over the preceding 12 months, requirements and serious concerns were raised separately in writing with the registered provider regarding insufficient care and hotel services staffing and the poor/inadequate arrangements for staff recruitment, induction, training and development, together with a lack of records in respect of these. Due to persistent breaches of identified Care Homes Regulations 2001, the Commission held a management review and subsequently wrote to the registered provider who was required to take urgent action and provide an Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 22 improvement plan detailing how the necessary changes were to be made to comply with the regulations and to improve outcomes for service users. This was provided and a meeting held with the provider to discuss matters. During this inspection, the arrangements for staffs’ recruitment, deployment, induction and training were discussed with the manager and staff and associated records examined. These included staff duty rotas, the personal and recruitment files of four of the most recent staff starters, together with staff recruitment, induction and training records and training plans. At the time of the inspection, there were 18 service users accommodated. And details of their dependencies were provided. Considerable improvements had been made in respect of the above in accordance with the home’s improvement plan. Staff personal files contained all relevant information as required for the purposes of their recruitment, induction and training. Overall, there was good progress made in respect of the home’s plan of staff induction and training, and audits of these were being undertaken by the manager on a monthly basis in order to monitor progress. Eighty four percent of staff had either completed (x 3) or were undertaking at least NVQ level 2 in care. Fifty seven percent had undertaken food hygiene and awareness, eighty-five percent moving and handling training, eight percent fire and ninety percent abuse awareness. All staff had received dementia care training, COSSH/health and safety and medicines training (in accordance with their responsibilities for the latter) and all existing staff had undertaken a revised and suitable programme of induction, as per new staff starters. However, up to date figures regarding infection control and first aid training/instruction were not provided. Staff said access to training was much improved and that they were better supported. Morale was improved. Discussions were held with staff about regarding the arrangements for staff deployment and service users needs and dependencies. Majority consensus was that staffing levels were satisfactory, although it was felt that there were periods when service users behaviours impacted on these. However, there were clear improvements resulting from the provision of additional kitchen staff cover, together with the recruitment of the activities co-ordinator and acting manager. To assist in staff planning and deployment, service users’ dependencies were being closely monitored, although there was no formalised method/tool for assessing and mapping service users wandering behaviours, which may also assist in this process. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The improvement in the arrangements for the management and administration of the home now better promote and protect service users’ best interests and their health and welfare. EVIDENCE: The home has been without a registered manager for approximately one year, with three acting managers since January 2006 to date. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 24 At the previous inspection of this service in September 2006 we judged that management and administration arrangements in the home were unsatisfactory and that residents best interests, health and welfare were not always effectively promoted or protected and we subsequently wrote to the registered provider and identified where regulations were being persistently breached. We also held a meeting with the representatives of the registered provider who provided a detailed improvement plan in respect of those areas, together with details regarding their proposals for the immediate operational management of the home. (Areas of improvement as assessed during this inspection are detailed under the relevant sections of this report). In October 2006 a new manager was appointed for the home, although she has, to date not submitted an application for registration to the Commission. Discussions were held with the manager during the inspection regarding her role and management systems in the home, which were vastly improved, particularly with regard to monitoring, systems auditing and reporting with clear development plans in place relating to the home’s policy and practise. The system for individual staff supervision had been re-instigated by the manager. Discussions were held with staff who said that the arrangements for their supervision and support were more satisfactory. The acting manager advised that she had met with individual representatives/relatives of service users and had developed a newsletter, which was to be sent out to them from the end of January on a regular basis. The acting manager was also planning regular resident/relative meeting. Progress will be assessed with these at the next inspection of this service. The arrangements for the management and handling of service user monies for those case tracked were examined and were satisfactory. A number of records, which are required to be kept in the home, were examined. A number of requirements were made in respect of records at the previous inspection of this service. Theses were complied with at this inspection. Records examined included service user care plans, health care records/medicines records, staff personal/recruitment records, training records, maintenance records and a full environmental risk assessment. Information was not available in respect of staff training in infection control and first aid and there was no maintenance record/certificate provided in respect of hot and cold water systems including legionella testing. See also staffing section of this report regarding progress to date with core health and safety training/safe working practise. Also at the previous inspection of this service serious concerns were raised separately in writing with the registered provider regarding substances, which Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 25 may be hazardous to health such as cleaning materials being left out around the home in areas accessed by service users. At this inspection, these were seen to be stored safely and were not left out. Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 26 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 3 2 Barnfield Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 Requirement Suitable arrangements must be made for the storage of medicines waiting return collection by way of a suitable metal cupboard and correct fitting of the CD storage cupboard must be ensured. A statement summary must be provided to the Commission of the complaints made during twelve months preceding this inspection and the action taken in response. Attention must be given to ensuring safe access to the garden area for service users. The staff training programme must be effectively completed (and sustained) and include recorded arrangement for infection control and first aid training/instruction for staff. A person must not manage (or carry on) a care home without being registered. Action to be taken to ensure compliance with the Care Standards Act 2000 – manager registration application to be submitted to the DS0000064197.V324586.R01.S.doc Timescale for action 09/03/07 2. OP16 22 28/02/07 3. 4. OP19 OP30 13, 23 18 31/05/07 31/03/07 5. OP31 CSA Pt 2,11 28/02/07 Barnfield Manor Care Home Version 5.2 Page 28 6. OP38 13 Commission. Evidence/certificate of testing and maintenance of the hot and cold water systems, including legionellas testing must be provided. 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Opportunities for service users stimulation and relaxation activities should be further developed in accordance with recognised and evidence based practise concerned with the care of persons with dementia. For example the provision and use of sensory equipment and materials for reminiscence therapy. (NMS OP27 also applies here). Consideration should be given to the introduction and use of an evidence based assessment tool, such as dementia care mapping (by way of suitable staff training in respect of this) in order to better inform the care planning and management of service users who have wandering behaviours and also staff deployment arrangements. Consideration should be given to developing bathroom décor to provide a more inviting and relaxing environment for service users. Development of the environment should continue with regard to the orientation of service users and their dementia care needs in accordance with relevant guidance. 2. OP16 3. 4. OP19 OP19 Barnfield Manor Care Home DS0000064197.V324586.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Manor Care Home DS0000064197.V324586.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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