Inspection on 14/10/05 for Barnfold Cottage

This inspection was carried out on 14th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Barnfold Cottage 27/09/07

Barnfold Cottage 05/07/06

Barnfold Cottage 31/12/05

Barnfold Cottage 17/03/05

Barnfold Cottage 12/10/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Barnfold Cottage 400/402 Blackburn Road Westend Oswaldtwistle Lancashire BB5 4LZ Lead Inspector Unannounced Inspection 14th October 2005 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 Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Barnfold Cottage Address 400/402 Blackburn Road Westend Oswaldtwistle Lancashire BB5 4LZ 01254 381348 01254 381348 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) Mrs Diann Judith Webster Care Home 14 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (13) of places Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The care home may provide service for one named service user with dementia who is over 65 years of age. 17th March 2005 Date of last inspection Brief Description of the Service: Barnfold Cottage is registered with the Commission for Social Care Inspection (CSCI) to provide personal care and accommodation to 13 older people and to one older person with dementia. The home is situated on the main road between Oswaldtwistle and Blackburn. The premises are a result of the amalgamation of two cottages and a barn. There are garden areas on both sides of the building and a tarmac patio area to the rear. There is parking at the rear of the premises and on the road at the front. The home is close to local shops, and on a bus route to the town centres of Blackburn and Accrington. The home provides accommodation in 10 single bedrooms and 2 double bedrooms. There are two communal lounges, a smoking lounge and a dining room. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. SUMMARY OF THE INSPECTION ON THE 14TH OCTOBER 2005 This inspection was an unannounced inspection. The staff and residents in the home did not know the inspectors were to visit. The purpose of the inspection was to: assess important areas of life in the home that should be inspected over a 12 month period; check the progress of previous legal requirements and good practice recommendations; investigate a complaint made by a relative of one of the residents; investigate some other matters of concern that another relative had brought to the attention of the inspector and to check other matters in the home which came to the inspector’s notice. Two inspectors visited the home, and the inspection took 7 hours. It involved talking to residents, a tour of the premises, looking at resident’s care records and other documents, and discussion with the deputy manager, Mrs Audrey Moore and member of staff Karen Ward. Six residents were spoken with, and others were observed in their routine daily activities. Four residents and three relatives completed comment cards. One district nurse who was visiting the home at the time of the inspection spoke briefly to the inspectors. The significant views expressed by all the people involved have been summarised in the report. Please note.This summary is written primarily for the residents of the home and the registered person should ensure that they have access to this. She should also ensure that the full report is made available to all interested people, including the residents. What the service does well: Residents told the inspectors that staff were “ very kind” and “very nice”, and that they felt well cared for. One Relative who gave her views on a comment card stated that she “enjoyed her visits” to the home and that “everyone was very kind”. Residents also told the inspectors that the home’s routines were flexible enough to suit their individual preferences. They could get up and go to bed at times of their choosing, and eat their meals when and where they chose. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 6 Residents praised the meals that were served, and one stated that staff went to the trouble of cooking their favourite meals. There was a good choice for breakfast including a cooked option. What has improved since the last inspection? What they could do better: The way residents are admitted to the home could be improved. A thorough assessment of what the staff need to do to look after people properly, and meet their physical and emotional needs, must be carried out. Some residents care records would benefit from more details about what staff need to do to look after them. The way the home manages and administers medication must be improved to make sure the residents are protected from poor practices and mistakes. The records kept of the training carried out by staff must be improved so that it is clear what training is needed for the benefit of staff and residents. There were concerns about residents’ safety when using the stair lift. The safety strap must be used when necessary, and all instructions for the residents’ needs for staff help and safety on the stair lift, must be written down for staff use. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 7 The premises must be improved in a number of ways. Some maintenance repairs and decorating must be carried out to make the home look better and more comfortable for residents. In addition the heating system, the fire doors and the electrical wiring system must be improved to ensure the comfort and safety of the residents. 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. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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 Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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, & 5. Standard 6 was not applicable The home’s admission and assessment procedures must be improved so that it can be fully determined whether or not the home can meet the needs of prospective residents. EVIDENCE: Though the statement of purpose and the service user guide were not assessed at this inspection, these documents had previously been assessed as being in accordance with legal requirements and standard 1. The viewing of some residents’ records showed that improvements could be made to the home’s admission procedures and the assessment process. There was no social work assessment for one resident who had been admitted under care management arrangements, and the in house assessment was not dated. It was therefore not possible to determine whether or not this had been undertaken prior to admission. Another resident had been recently admitted to the home from hospital, as an emergency, following a visit and a basic assessment by the deputy manager. However a comprehensive assessment had still not been undertaken and the resident’s needs were not fully recorded. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 10 Staff were therefore not fully informed as to this person’s health and personal care needs. The documentation used for in house assessments covered all the matters listed in the standard and therefore formed an appropriate format for a comprehensive assessment. Assessments must be kept under review. Following a complaint investigation to the home in May, the owner/manager was required to ensure that a reassessment of one resident was undertaken. This had determined that Barnfold Cottage could no longer meet her needs, and resulted in a transfer to a more suitable placement. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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, 9 & 10 The care plans contained useful information about the care needs of the residents, including risk assessments on moving and handling. However for some residents more details would be beneficial. Medication systems in the home must be improved in order to avoid mistakes and protect residents. Residents were satisfied that staff respected their privacy and dignity and looked after them appropriately. EVIDENCE: One care plan viewed set out the residents’ health, personal and social care needs. The other care plan of a recently admitted resident would benefit from greater detail (see above) so that staff had clear instructions about how to look after this person. One care plan viewed contained a detailed moving and handling risk assessment, and there were detailed instructions in the resident’s bedroom on how she should be transferred to the commode during the night by one carer using moving and handling equipment. However it is strongly recommended that risk assessments be carried out on the use of the stair lift which gives Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 12 instructions to staff on individual residents’ needs for assistance (see standards 22 and 38) Residents’ signatures on the care plans indicated that residents had been involved in the preparation of these. There was also evidence that the care plans were being reviewed at regular intervals. With respect to medication, some of the requirements and recommendations made at the previous inspection by the pharmacy inspector had been met; others had not and these are repeated. These, and other requirements made from this inspection, must be addressed to ensure the safe management and administration of medicines in the home. These include undertaking risk assessments for residents administering their own medication and providing them with a suitable lockable storage facility. All medication, including creams, must be stored securely. Medication must be verified on admission and listed in the care records. All out of date medication must be returned to the pharmacist, and items, including needles for blood sugar testing, prescribed for one resident should not be used by other residents. All secondary dispensing must cease. Residents spoken with and those who completed comment cards stated that the staff respected their rights to privacy and dignity and treated them well. One resident stated that “all the staff were very nice”, another said “staff were very kind”. The inspectors observed staff treating residents appropriately and kindly, and that treatment carried out by the district nurse took place in the privacy of the resident’s bedroom. Since the previous inspection two relatives expressed the same concern about the attitude of one member of staff who allegedly spoke uncivilly and harshly to some residents. One of these allegations was the subject of a complaint investigation. At the time of this investigation there was evidence that this member of staff spoke to some residents in an inappropriate way. Since then the home had carried out its own checks and training to ensure that all staff treat all residents appropriately and with respect. At this inspection there was no evidence that this behaviour had continued, though one resident stated that the member of staff still spoke unkindly. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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 & 15 The daily routines were flexible enough to suit individuals’ needs and preferences, and some leisure activities were organised which also suited residents’ preferences. Residents were encouraged and assisted to keep in touch with their relatives and friends. The meals served in the home appeared varied and wholesome and appeared to suit residents’ tastes. EVIDENCE: There was evidence that the home’s routines were flexible enough to suit residents’ needs and preferences. The inspection confirmed that residents could rise and retire to bed at times of their choosing, could have their favourite meals, and eat in their bedrooms if they wish. Since the previous inspection two complaints have been made about a lack of leisure activities, and that activities were advertised but didn’t take place. The investigations, including looking at the home’s records and talking to residents, showed that activities were organised and included, games of bingo, quizzes, visiting entertainers / singers and “birthday party teas”. Most residents spoken with, and those who completed comment cards, stated that they were satisfied with the leisure activities provided in the home. One resident stated that she “enjoyed regular quizzes” but another resident said, “there was not much going on”. There was no evidence that activities or events were advertised and then did not take place. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 14 Residents were encouraged and assisted to keep in touch with relatives and friends. Visitors who completed comment cards stated that they were made welcome in the home at any time and one said she regularly had a meal there. One visitor said that “she really enjoyed her weekly visit to the home” and that “everyone is so kind”. According to the records viewed, residents spoken with and those who completed comment cards, the food served was enjoyable, varied and wholesome. One resident stated that staff would cook her favourite meals and that “you could have anything you wanted at breakfast time”. At the time of the inspection residents were seen eating their meal in parts of the home of their own choosing, including bedrooms. Staff gave appropriate assistance to those residents who required it. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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 & 18 Residents and relatives knew how, and who to contact regarding concerns and complaints about the home. However not all relatives were satisfied that their concerns were dealt with properly by the manager. The home must ensure that its policies and procedures protect the residents from all forms of abuse, including verbal abuse. EVIDENCE: The home’s complaints procedure was posted on the home’s notice board and relatives who completed comment cards stated that they knew how to make a complaint. However one relative expressed a concern to the CSCI that not all concerns and complaints were dealt with appropriately by home. Residents stated that they knew who to speak to if they were not happy about any aspect of their care. However the complaints procedure must contain the telephone number of the CSCI. Three complaints had been recorded and investigated by the home in 2005. Also since the previous inspection two complaints had been made to the CSCI by relatives of residents at Barnfold Cottage. One of these was investigated in May and another was investigated at this unannounced inspection. In addition another relative had expressed some issues of concern to the CSCI and these were also investigated on this unannounced inspection visit. All these matters investigated have been summarised in the appropriate sections of the report. A report of the CSCI’s investigation into the complaints in May of this year is available to the public on request. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 16 The home had a “ protection of adults from abuse” policy and procedures, and which included a whistle blowing policy. The deputy manager informed the inspectors that, as several members of the registered manager’s family work in the home, staff are encouraged to inform the deputy manager of concerns about poor practice and behaviour. It is strongly recommended that the written whistle blowing policy be amended to emphasise this line of action open to staff. Most residents spoken with, stated that they felt safe living in the home and that all staff treated them appropriately. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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, 22, 25 & 26 The home was clean and fresh, but there were outstanding repairs that need to be carried out to improve the environment. This includes repairs to the central heating system to ensure residents are comfortably warm throughout the home, and safe from the hot surface temperatures of portable heaters. EVIDENCE: The location and layout of the home was suitable for it’s stated purpose and some aspects of the premises had been improved since the previous inspection, for example some carpets and bedding had been replaced. However there were numerous areas of the home that should be improved in terms of maintenance, decoration and safety. These matters were discussed fully with the deputy manager and some are referred to specifically in the report. The manager must carry out a full audit of the premises and provide the CSCI with an action plan on how all the premises matters will be addressed. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 18 The pegging open of fire doors must cease, and the door to a cupboard storing combustible materials must be kept locked. These matters were outstanding from the previous inspection and must be addressed with priority. Also some fire doors were found to be in need of repair. The property was registered as a care home prior to the implementation of the National Minimum Standards in April 2002 on room sizes, communal space and toilet and bathing facilities, and therefore is exempt from having to meet these standards. There have been no changes to the property since April 2002 and all the residents were accommodated in single bedrooms. The home has a chair lift operating between the two floors, and several residents were using wheelchairs. Just prior to the inspection a relative expressed concern about the safety of the chair lift and the cleanliness of the wheelchairs. These issues were investigated at the inspection. The stair lift had been serviced but was found to be operating without a safety strap. Some residents needed assistance getting in and out of the stair lift to prevent them banging their feet against the wall. Risk assessments must be undertaken on the use of the stair lift, the assistance required and procedures to be adopted to protect residents from hurting themselves. Other aspects of moving and handling were carried out satisfactorily and there was appropriate equipment, including a hoist. The wheel chair viewed had some food stuck to the frame and the manager must ensure that all the wheelchairs are kept clean. In some bedrooms there were no cords on the call bells and residents could not reach these from the bed. The manager must ensure that the call bell is accessible to residents who are in bed. A relative had reported problems with the central heating system and stated that it did not work in certain areas of the home. On the day of the inspection some radiators in the bedrooms were not working, and portable electric heaters were in use. At least one of these was hot to touch. The deputy manager stated that one of the 3 boilers was faulty and that a heating engineer had been asked to make the necessary repairs. As a matter of priority the registered person must ensure that the home has a suitable heating system and that residents are not at risk from hot surfaces. Since the previous inspection two complaints had been made about the cleanliness of the home. One complaint was investigated in May and found to be “upheld”. Just prior to this inspection a complaint was made about the cleanliness of one of the bedrooms. However at this inspection, this bedroom and other areas of the home were found to be in a satisfactory state of cleanliness. All areas of the home viewed were free from offensive odours and the general cleanliness and tidiness of the home was improved from the previous visit referred to above. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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 & 30 The numbers of staff on duty met the needs of the present residents, but these levels need to be kept under continuous review, particularly at night, to ensure the changing needs of the residents are met. Residents were protected by the home’ s recruitment procedures, but there must be documentary evidence that staff are trained according to the needs of the residents. EVIDENCE: At the time of the inspection it appeared that there was sufficient staff to meet the needs of the residents and to ensure that standards in relation to meals and cleanliness were maintained. However prior to the inspection a relative had expressed concern about only one member of staff being on duty at night, and the arrangements for transferring residents who needed two carers. The inspectors found no evidence that the residents were being moved and transferred inappropriately. Residents had moving and handling assessments and there was a hoist and other equipment. However the arrangement of one waking night staff, and one on call off the premises, needs to be kept under review to ensure the changing needs of the residents are met. The home had not yet achieved the target of 50 of care staff being trained to at least NVQ level 2, but was working towards this target. The viewing of the records of the most recently appointed members of staff showed that the home’s staff recruitment procedures had improved following the previous inspection. However the CRB disclosures, or the details of these, Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 20 were not available at the time of the inspection and the registered person must send evidence of the CRB disclosures to the CSCI by the 28/10/05. The induction training undertaken by staff must also be recorded. A relative had expressed concerns that there was a person working occasionally in the home, who was not on the pay roll, and therefore who had not been recruited properly. Records showed that this person was on the payroll and that she was appointed in 2003. Courses undertaken by staff included the TOPSS college based Induction training, first aid, moving and handling and challenging behaviour. Training and development files had been set up for individual members of staff, but these had not been completed. Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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 & 38 The registered manager has relevant qualifications for the manager of a care home but must ensure that the home complies with the Care Homes Regulations. There were some urgent matters to address in the home in order to ensure the health and safety of the residents and staff. EVIDENCE: The home’s owner and registered manager, Mrs Webster, was suitably qualified. The deputy manager had successfully completed NVQ level 4 in “Care” and expected to complete the Registered Managers Award in the near future. The owner/manager informed the inspector that earlier this year the home had admitted a resident over their registered numbers. This is a breach of the homes registration under the Care Standards Act 2000 and should the Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 22 Commission become aware of a similar occurrence in the future then enforcement action will be considered. Some health and safety aspects of the home must be improved, and some of these have these been referred to in other parts of the report, for example the stair lift, the fire doors and the central heating system. In addition following a complaint received by the CSCI, the position and condition of a flex between the two lounges was checked. It was found to be in an unsafe condition and was removed immediately. There were concerns about the position of flexes and the use of multiple socket leads in other areas of the home. The manager must ensure that the condition of the wiring throughout the home and the use of multiple socket leads are safe. A current certificate of portable electrical appliance testing was seen. procedures and fire records were found to be satisfactory. Fire Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 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 2 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X 2 X X 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 1 Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 24 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 OP3 Regulation 14 (1)(a)(b) Requirement The registered person must ensure that residents are not admitted without a comprehensive assessment and that the home obtains a copy of that assessment undertaken by social workers. The manager must ensure that all relevant details regarding the health, personal and social care needs are recorded on the care plan. The manager must ensure that risk assessments be completed and reviewed regularly for all residents who wish to self medicate. All items being self administered should be clearly marked on Medication Administration Record charts. (Previous timescale of 30/04/05 not met) Residents keeping medication in their rooms must be provided with a suitable lockable storage facility. (Previous timescale of 30/04/05 not met) All medication, including creams, must be stored securely. DS0000009428.V257965.R02.S.doc Timescale for action 14/10/05 2 OP7 15 1 &17(1)(a) sch 3 13 (2) 11/11/05 3 OP9 04/11/05 4 OP9 13 (2) 11/11/05 5 OP9 13 (2) 14/10/05 Barnfold Cottage Version 5.0 Page 25 6 7 OP9 OP9 13 (2) 13 (2) 8 9 10 OP9 OP16 OP19 13 (2) 22 (7)(b) 23 (2)(b) 11 OP19 23 (2)(d) 12 OP19 23 (4)(c) 13 OP19 23 (4)(c) Medication must be verified on admission and listed in the care records Items prescribed for one resident, including needles for blood sugar testing, should not be used by other residents. All secondary dispensing must cease The home’s complaints procedure must include the telephone number of the CSCI The manager must ensure that all parts of the home are kept in a good state of repair and provide the CSCI with an action plan as to how all matters identified will be addressed All parts of the home must be kept clean, including wheelchairs, and reasonably decorated. The registered person, shall after consultation with the fire authority, make adequate arrangements for the containing of fires and must • Cease the pegging open of fire doors with wooden wedges. • All doors to cupboards storing combustible materials must be kept locked. (Previous timescale of 30/04/05 not met) All faulty fire doors must be repaired. The CSCI must be informed of the action taken by the 28/10/05 The manager must ensure that there is a safety strap for the stair lift. The CSCI must be notified of the action taken by the 28/10/05 Risk assessments must be undertaken on the use of the DS0000009428.V257965.R02.S.doc 14/10/05 14/10/05 14/10/05 07/11/05 28/10/05 28/10/05 14/10/05 11/11/05 14 OP22 13 (4)(a) 11/11/05 15 OP22 13 (4)(a) 11/11/05 Page 26 Barnfold Cottage Version 5.0 16 17 OP22 OP25 23 (2)(n) 23 (2)(p) 18 OP25 13 (4)(a) 19 OP27 18 (1)(a) 20 OP29 19(1) amded reg sch2 21 OP38 13 (4)(a) stair lift, the assistance required and procedures to be adopted to protect residents from harm. The CSCI must be notified of the action taken by the 28/10/05 A call bell facility must be accessible to residents who are in bed. The manager must ensure that there is suitable and comfortable heating throughout the home. The CSCI must be notified of the action taken by the 28/10/05 The manager must ensure that residents are protected from the hazards of hot surfaces. The CSCI must be notified of the action taken by the 28/10/05 The manager must keep staffing levels under review particularly night staff to ensure they meet the changing needs of the residents The manager must provide evidence to the CSCI of the CRB disclosures of the two most recently appointed members of staff. Records must be kept of the induction, and other training undertaken. All parts of the home must, so far as possible, be free from hazards to their safety and all aspects of the electrical wiring must be safe. The CSCI must be notified of the action to be taken. 18/11/05 25/11/05 25/11/05 14/10/05 28/10/05 28/10/05 Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP3 OP9 OP9 OP18 Good Practice Recommendations The registered person should ensure that when a person is admitted as an emergency a comprehensive assessment is undertaken within 2 – 4 working days. It is strongly recommended that the medication found in a residents’ drawer is checked and sorted, and any out of date items returned to the pharmacist. It is recommended that accurate totals are recorded of controlled drugs in the home It is recommended that the whistle blowing policy be amended to emphasise that staff can approach the deputy manager as well as the manager with concerns about poor practice and behaviour. 50 of care staff should be trained to at least NVQ level 2 by the end of 2005. 5 OP28 Barnfold Cottage DS0000009428.V257965.R02.S.doc Version 5.0 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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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