Inspection on 05/07/06 for Barnfold Cottage

This inspection was carried out on 5th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 31/12/05

Barnfold Cottage 14/10/05

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 Mrs Pat White Unannounced Inspection 5th July 2006 09:45 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.V295831.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. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 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.V295831.R01.S.doc Version 5.2 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. 31st December 2005 Date of last inspection Brief Description of the Service: Barnfold Cottage is situated on the main road between Oswaldtwistle and Blackburn. 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. The accommodation and facilities are on two floors that are linked by a stair lift. The weekly fees charged at the time of this inspection were between £295 and £355, with additional charges for hairdressing, magazines and newspapers. There is written information about the home in the documents called the Statement of Purpose and the Service User Guide. These are available for existing residents, and to help prospective residents and their relatives make a choice about whether or not the home is suitable. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced “key” inspection, the purpose of which was to decide an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People and checking the progress made on the matters that needed improving from the previous inspection. The inspection took nine and a half hours and involved: talking to residents (six were spoken with in some depth), touring the premises, observation of life in the home, looking at residents’ care records and other documents, talking to a member of staff and discussion with the deputy manager, and the owner Mrs Diann Webster. Survey questionnaires were sent to the home for residents and relatives to complete, and eight were received at the time this report was written. Some of the views expressed in conversation and in these questionnaires are summarised in this report. Comment cards were also sent to General Practitioners and the District Nursing Team. One GP completed and returned a questionnaire and the views are also included in the report. What the service does well: Residents told the inspector that staff were “ very kind” and “very nice”, and one said “I’ve no grumbles at all”. Residents were happy that the home’s routines were flexible enough to suit their individual preferences. Residents could get up and go to bed at times of their choosing, and eat their meals when and where they chose. There was a good system of checking the care needs of the residents and whether their needs had changed. There was also a good system of assessing and reducing the risk to individuals in their routine activities, such as moving around and using the stair lift. There was also good written information about people’s preferred routines and “likes and dislikes”. Residents spoke favourably about the activities that were organised in the home such as a BBQ and a musical entertainer. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 6 Residents praised the meals that were served, and one stated that staff went to the trouble of cooking her favourite meals. The meals had improved further since the last inspection, as a choice of two main courses and desserts had been introduced at the residents’ request. There was also a good choice for breakfast, including a cooked option. The home was comfortable, clean and homely. Residents spoke favourably about their bedrooms. The way that staff were recruited to work in the home was thorough, and helped to protect the residents from unsuitable staff. The manager, deputy manager and some of the care staff had worked in the home for a number of years. This meant that a group of staff, familiar to the residents, understood their needs and looked after them. The home’s training courses for staff were being developed to make sure that staff were properly trained to look after the people who lived in Barnfold Cottage. The home was a safe place for the residents to live in, and all the necessary checks on the premises and equipment had been carried out. What has improved since the last inspection? The way that residents are admitted to the home had improved. More information about the residents, and what staff needed to do to look after them, was collected before residents were admitted to the home. The information added later about how people needed to be looked after had also improved. There were a number of further improvements to the premises. The fire precautions had been improved and a bathroom sink had been replaced. The water supply had been tested and found to be free from the Legionella bacteria. The training that staff were doing had improved and more staff had the qualifications recommended for people working as carers. This enabled staff to understand the residents’ needs and look after them better. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 7 The home was better at finding out the views of the residents about the home and how things could be changed. There had been some changes based on these views, for example a greater choice of meals. The way the residents’ finances were managed had improved and better records were kept. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. Barnfold Cottage DS0000009428.V295831.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 Barnfold Cottage DS0000009428.V295831.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4. Standard 6 was not applicable Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The home’s admission procedures, including pre admission assessments helped to determine whether or not the home could meet people’s needs, but the home did not confirm this in writing to prospective residents and shouls avoid short notice admissions if possible. EVIDENCE: There was useful information about the home – The Statement of Purpose and the Service User Guide – which met legal requirements, but the Statement of Purpose still did not fully explain the pre admission assessment procedures and emergency admissions. The records viewed of a resident who had been recently admitted showed that the deputy manager had carried out a pre admission assessment and that a comprehensive risk assessment regarding moving and handling and the risk of falling had also been carried out. The relatives had looked around the home before a decision was made. Another resident had been admitted to the home on the same day that the pre admission assessment had been undertaken, and Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 11 prior to the social worker’s assessment being received. This made it difficult to determine whether or not the home could meet the needs of this person. Since the previous inspection this assessment documentation had improved and covered all areas in standard 3.3. However the registered person did not confirm in writing that the home could meet the needs of prospective residents. Residents overall indicated that the home was meeting their needs. Seven residents who completed the survey questionnaires stated that they got the care they needed at the right time. One said she “sometimes” did. Barnfold Cottage DS0000009428.V295831.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The health and personal care needs of the residents were met. Some parts of the residents’ health and personal care needs should be written in the care plan in more detail. Some medication procedures need to be improved to ensure the safe administration of medicines to residents. The residents’ rights to privacy and dignity were upheld. EVIDENCE: All residents had care plans, and which had been improved since the previous inspection. They now contained information about oral care and foot care. There was a useful section called residents daily living plan which gave information about residents preferred routines. There were good risk assessments, and since the previous inspection risk assessments with respect to falling had been implemented. However the care plans looked at were not written in sufficient detail in some matters to enable the staff to know what assistance the residents needed. For example what assistance is required to look after teeth and whether or not assistance is required for the toilet. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 13 There was evidence that the care plans had been reviewed approximately monthly and updated as necessary. Residents had signed their assessments and care plans. Residents received the health care they needed, and since the previous inspection some practices had improved, including the introduction of nutrition assessments and pressure area assessments. However for one resident whose records were looked at, the pressure area assessment had not been completed properly, though equipment supplied from the district nurses was in use. Doctors and district nurses visits were recorded in the daily notes but there was no reference to district nurses’ intervention in the care plans. One General Practitioner stated on a comment card that he was satisfied with the overall care of his patients, and the way the staff worked in cooperation with him, and followed his instructions. Residents’ medication in general was managed and administered satisfactorily, and a number of legal requirements from the previous inspection had been met. The home had comprehensive policies and procedures that covered all the necessary parts of medication management, and a number of good practices were followed: Accurate records of medication, entering and leaving the home were kept, staff verified the medication with the GP when people were admitted and prescriptions were checked at the chemist prior to dispensing. At the time of the inspection staff responsible for administering medication were undertaking suitable training. However some errors were found. The criteria for PRN and variable dose medication was not defined or explained on or near the MAR sheets, and this is outstanding from the previous inspection. There were some gaps on the MAR sheets viewed: For one resident it was not clear whether or not the medication had been given, as there was no explanation on the MAR sheet. For another resident one weekly dose of medication had not been given but there was no explanation for this on the MAR sheets. For another resident, two doses of a medication had been signed as given but they had not been. Also for one resident the number of Temazepam recorded in the Controlled Drugs register as remaining did not tally with the number left in the bottle. There was one extra in the bottle and this had not been noticed. Residents spoken with and those who completed the survey stated that staff treated them appropriately and respected their right to privacy such as staying in their bedrooms if they wished and eating in their bedrooms. One resident stated how kind a male member of staff was, and that he behaved like a real gentleman. However written complaints from a relative about members of staff speaking inappropriately to her mother had been recorded and investigated. The records showed that these had been investigated satisfactorily. Barnfold Cottage DS0000009428.V295831.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. There were varied leisure activities which suited the needs and preferences of the majority of residents. Residents had sufficient choices in their everyday lives and were enabled to maintain contact with their relatives and the community. The food served was appetising and wholesome and suited the needs and preferences of the residents. EVIDENCE: The routines of daily living were flexible to suit individuals’ preferences, and some of these preferences were written on the care plans. Residents spoken with stated that they could get up and go to bed at times of their choosing and that there was a choice of meals and where to eat the meals. Residents were asked at residents meetings what leisure activities they would like, and enjoyed regular games of Bingo and quizzes. Residents were looking forward to a BBQ and a trip to St Annes. Residents’ religious preferences were observed. Seven out of the 8 residents who completed the survey stated there were suitable leisure activities. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 15 Community contacts were encouraged. Written information about the home stated that visitors were welcome in the home at any reasonable time. Some relatives who were visiting at the time of the inspection confirmed this. The visitor spoken with also stated that staff were friendly and approachable and that they were invited to some events in the home. Residents could exercise choice in some areas of their lives. They could bring small items of furniture to personalise their rooms and as stated above there was choice in such matters as rising and retiring times, whether or not to stay in their rooms, leisure activities and in the food served. The member of staff interviewed recognised the importance of residents choice and confirmed the examples given above. The residents survey questionnaires showed a high level of satisfaction with the food served, with comments showing that residents appreciated the recent introduction of a choice of 2 main meals and dessert at lunch - time. The menus seen confirmed these choices. Residents stated in conversation that the food was good and one resident confirmed that the staff were very obliging and would make her favourite meals. She also confirmed that there was a good choice for breakfast including fruit and a cooked option. Menus supplied for the lunchtime meal showed a range of fairly traditional English dishes such as meat pie and roast dinners. Drinks and snacks were served throughout the day. Barnfold Cottage DS0000009428.V295831.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The complaints procedure was accessible to most residents and visitors and residents stated that they knew who to speak to if they had any concerns. There were satisfactory policies and procedures to protect the residents from abuse. EVIDENCE: The home had an adequate complaints procedure. The home’s records of complaints and information supplied in the pre inspection questionnaire demonstrated that relatives knew how to make a complaint and that these were investigated (see standard 10). All residents who completed the survey stated that they knew who to speak to if they were not happy about any aspect of their care. Residents that were spoken with and who completed the survey stated that they had no complaints. The home had a “ protection of adults from abuse” policy and procedures, and which included a whistle blowing policy. As several members of the registered persons family work in the home, staff were encouraged to inform the deputy manager of concerns about poor practice and behaviour. There had been no allegations or suspicions of abuse within the last 12 months. Staff had undertaken abuse training as part of their NVQ courses and the homes training records showed that staff had also undertaken in house adult abuse training and challenging behaviour training. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The home was comfortable, clean and furnished and decorated to a satisfactory standard. The overall safety and general maintenance of the premises had improved considerably over the last year and the home provided a safe place for residents. 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. A number of legal requirements had been met, such as an ill fitting door at the time of the last inspection had been repaired and a damaged bathroom sink had been replaced. The fire precautions were satisfactory and a new fire risk assessment had been completed following a recent fire safety inspection by the fire service. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 18 The communal areas of a two part lounge and a dining area and a smoking area were adequately furnished and decorated and domestic in style, and accessible to residents. The outside areas, with patio furniture, were tidy and well kept and also accessible to the residents. The bedrooms were clean and adequately furnished and residents had brought some personal possessions with them. Residents stated they were satisfied with their rooms and were comfortable. Several residents spent time in their bedrooms during the day and the rooms were meeting their needs. However regular audits of the premises were not undertaken, and several minor matters regarding the environment needed attention. All areas of the home that were viewed were free from offensive odours and the general cleanliness of the home was of a satisfactory standard. The laundry was situated in an “out house” at the back of the property. Laundry procedures were found to be satisfactory at a previous inspection. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The numbers of staff on duty appeared to meet the needs of the residents most of the time, but it was unclear if this was the case at the weekends when there were less staff on duty. The staff recruitment procedures were sufficiently thorough to help protect residents from unsuitable staff. Staff were developing relevant skills and competences through the home’s staff training programme. EVIDENCE: There was evidence from the rotas and discussions, that during the week the numbers of staff on duty were adequate for meeting the needs of the residents. However at the weekends there were only two members of staff on duty for caring and catering duties, and it was not clear that this was enough to meet the needs of the residents at certain times of the day. There were some hours on the rota designated to cleaning, during the week, and the rest of the time the care staff were responsible for keeping the home clean. This arrangement appeared satisfactory for maintaining standards of cleanliness in the home. The member of staff spoken with stated that she felt there was a very good and supportive staff team, and there was a good atmosphere in the home. The pre inspection questionnaire and staff training records showed that 46 of staff were trained to at least NVQ level 2. All others apart from 2 members of staff were completing NVQ courses, so the target of 50 of care staff being Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 20 trained to this level will soon be achieved. Records, including individual staff records, and discussion with a member of staff, showed that the staff training programme was also being developed according to Government guidelines and the needs of residents and staff. Training in dementia was planned to assist the staff look after those residents with confusion and memory loss. Records of a new member of staff showed that the staff were recruited according to thorough procedures which helped to protect the residents from unsuitable staff. For example staff did not commence work until police checks and two satisfactory written references had been obtained. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Competent, qualified and experienced people managed the home. The home’s service quality monitoring systems demonstrated that the home was being run according to the views of the residents. The health and safety of residents and staff were promoted and the residents’ spending money was managed satisfactorily. However some of the home’s records could be improved to further safeguard residents’ interests. EVIDENCE: The home benefited from a stable management team. The registered person worked in the home as the manager, and there was a deputy manager. Both the registered person and the deputy manager have completed the relevant qualifications and attended other relevant courses. The member of staff interviewed stated that there was a good atmosphere in the home and that the Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 22 registered person and the deputy manager were supportive and approachable. She confirmed that there was a staff meeting every few months. The homes quality monitoring systems had improved. Since the previous inspection residents had completed service quality questionnaires. The comments had been analysed and there was evidence that the residents’ views were listened to, for example the manager had introduced a choice of two meals at lunchtime. There was a regular newsletter to inform residents of what was going on and how the service would change according to their comments and wishes. There were regular residents’ meetings. Relatives and visiting professionals were not yet involved in the quality monitoring exercises. The homes records of resident finances had improved. Appropriate records were kept of the fees paid by residents and accurate records of residents’ spending money received in the home, and spent on their behalf, were now being kept. However this spending money was not stored safely. Also the records kept of the food served in the home were incomplete. Care plans, and records relating to medication, have been referred to in other sections of the report. The health and safety of the residents and staff were promoted. Members of staff had the necessary health and safety training. The home’s fire precautions and records were satisfactory as checked by a recent fire safety inspection (see standard 19). The electrical wiring and the gas appliances had been appropriately tested. There had been a recent Environmental Health inspection, and the recommendation made had been complied with. There was a rolling programme of training in moving and handling, first aid and food hygiene. Since the previous inspection the homes water supply had been tested and found safe from the risk of the spread of Legionella. Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 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 OP4 Regulation 14 (1)(d) Requirement The registered person must ensure that following a comprehensive assessment, she confirms in writing whether or not the home can meet the prospective residents’ needs. The manager must ensure that all relevant details regarding the health, personal and social care needs are recorded on the care plan, including oral care and continence needs (Previous timescales of 11/11/05 & 16/03/06not met) The risk assessments for those residents vulnerable to pressure areas must be completed properly and any intervention required must be recorded on the care plans. A record of any nursing provided to residents, including a record of their condition, treatment and surgical intervention must be recorded on the care plans. All medication given to residents must be entered on the MAR DS0000009428.V295831.R01.S.doc Timescale for action 21/07/06 2. OP7 15(1)17(1 )a,sch3 11/08/06 3. OP7 15& 17(1)(a) Sch3,3n 28/07/06 4. OP7 15&17(1) (a)Sch3,3 k 17(1)(a), Sch3,3i 28/07/06 5. OP9 21/07/06 Barnfold Cottage Version 5.2 Page 25 6. 7. OP9 OP9 13 (2) 13 (2) 8. OP9 13 (2) 9. OP9 13 (2) sheets. All medication must be given unless there is a reason that is written on the MAR sheet The MAR sheets must be an accurate record of the medication given and staff must not sign that medication has been given if it has not. Accurate records of the Controlled Drugs administered must be kept and the number of Controlled Drugs remaining for individual residents must be the same as the balance recorded in the CD register. The criteria for the administration of PRN medication must be clearly defined and recorded on or with the MAR sheets. (Previous timescale of 09/03/06 not met) The registered person must review staffing levels, particularly at the weekend, and ensure that there are at all times enough suitably qualified, competent and experienced persons working in the home. The CSCI must be notified of the outcome of this review. Residents’ money given to the registered person for safekeeping must be stored securely. (Previous timescale of 02/03/06 not met) Records must be kept of all the food served including breakfasts teas and suppers 21/07/06 21/07/06 21/07/06 28/07/06 10 OP27 18(1)(a) 21/07/06 11. OP35 16 (2)(l) 21/07/06 12. OP37 17(2),Sch 4,13 21/07/06 Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 26 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 OP1 Good Practice Recommendations The statement of purpose should include details of the pre admission assessment procedures, emergency admission procedures and examples of how residents’ privacy and dignity are respected. (Repeated from the previous inspection) Short notice admissions and emergency admissions should be avoided if possible in order to ensure that there is adequate time to determine whether or not the home can meet needs. It is recommended that regular audits of the premises be undertaken to identify jobs that need doing. It is recommended that relatives and visiting professional be involved in the quality monitoring exercises. 2. OP3 3. 4. OP19 OP33 Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Barnfold Cottage DS0000009428.V295831.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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