Inspection on 17/08/06 for Barnham Manor

This inspection was carried out on 17th August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Barnham Manor 02/10/07

Barnham Manor 17/10/05

Barnham Manor 07/06/05

Barnham Manor 05/08/04

Barnham Manor 28/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Barnham Manor 150 Barnham Road Barnham Bognor Regis West Sussex PO22 0EH Lead Inspector Mrs S Rodgers Key Unannounced Inspection 17th August 2006 10:30 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 Barnham Manor DS0000039654.V301711.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. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barnham Manor Address 150 Barnham Road Barnham Bognor Regis West Sussex PO22 0EH 01243 551190 01243 551190 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) Barnham Manor Limited Mrs Sivagamee Curpen Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Barnham Manor is a Care Home registered to accommodate up to twenty-three service users in the category OP (Old age not falling into any other category) with N (Nursing). The weekly fees range from £375 to £500. Extras include hairdressing and chiropody. Inspection reports are made available to prospective residents or their relatives when they visit the home. Barnham Manor is located on the outskirts of the village of Barnham. Local shops and transport services are near by. Accommodation is provided on two floors: the first floor can be accessed by a passenger lift. The responsible Individual on behalf of the organisation is Mr Gary Curpen. Mrs Sivagamee Curpen is the registered manager in charge of the day to day running of the establishment. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours. Preparation for this inspection focused on a review of the pre inspection questionnaire, resident surveys, previous inspection reports and general correspondence. During the course of the inspection the inspector toured the home, spoke with residents privately in their own bedrooms or within the communal areas of the home in order to gain a sense of how the home is being run and how they experienced living at the home. Two staff members were spoken with formally and one informally in order to gain a sense of the support and training they receive in order to carry out their jobs and to gain insight into their knowledge of the aims and objectives of the homes philosophy of care. Four requirements and one recommendation have been identified at this inspection. The registered provider must inform the Commission of action to be taken and timescale in which compliance with regulations will be achieved by 30 September 2006. What the service does well: What has improved since the last inspection? What they could do better: Not all staff have received fire safety instruction at the recommended intervals of 6 monthly day staff and 3 monthly night staff. All staff must have training in adult protection procedures. This was addressed following the previous inspection however, there have been a number of new staff who have not had the training. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 6 The quality assurance and quality monitoring system must be completed and a report written based on information received via the audit. 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. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 7 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 Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 8 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): 3,6 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to moving into the home each prospective residents needs are assessed in order to ensure that the home can meet their needs. EVIDENCE: Written pre admission assessments were available and demonstrated that resident’s health, personal and social needs are assessed. Two residents spoken with who have recently been admitted confirmed that they were either visited in their own homes or visited Barnham Manor themselves for the day in order for the assessment to be carried out. The records of one resident indicated that a member of staff from the home had not assessed them however, a social services needs management assessment had been undertaken and a copy of the document was sent to the home prior to the person moving in. Intermediate care is not provided at Barnham Manor. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 9 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plan clearly set out the health, personal and social care needs of residents, which enables staff to maintain continuity of care. Systems are in place for the recording, administration, handling and disposal of medicines. All care needs are carried out in an appropriate manner ensuring that they dignity and privacy of residents are maintained. EVIDENCE: Four care plans were reviewed, they clearly identified the individual needs of service users. Care plans contained relevant information on identified care needs and intervention, including risk assessments for manual handling and nutritional assessments. All four care plans seen at this visit had been regularly reviewed each month. The care planning system records all doctors and other health professionals’ visits and nay treatments required. Comments from the residents surveys, some of which were completed by relatives indicated that the “medical attention is excellent”. One question from the survey asked “Do you receive Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 10 the care and support you need?” one comment received stated, “Sometimes junior carers can be abrupt and a little surly, rushing feeding. On the whole however, Brenda (manager) and her team are cheerful, professional and provide excellent, prompt and kindly care. Systems are in place for the recording, storing, handling, administration and disposal of medication. However Mrs Curpen needs to clarify as to whether the pharmacy she returns unwanted medication to has authority to dispose of medication in line with the pharmaceutical regulations. Medication is stored in two drug cupboards/trolley on the first and ground floor. There is also a lockable store room in which medication not in use can be stored. Medication Record Sheets were in good order. A picture of each resident is attached to their own medication record. Trained nurses administer all medication. Records of staff signatures and initials are kept. The inspector witnessed medication being administered, medication was dispensed from the medicine trolley directly to the resident. During the course of the inspection the inspector was able to observe staff maintaining resident privacy and dignity by knocking on doors prior to entering their rooms. Residents who were asked confirmed that staff ensure that they are appropriately covered when being taken to and from the bathroom. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 11 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A programme of activities is provided. Residents are enabled to maintain contact with family, friends and the community. Residents feel they can maintain some control over their lives. Meals provided are of a good standard. EVIDENCE: The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A programme of activities is provided. Residents are enabled to maintain contact with family, friends and the community. Residents feel they can maintain some control over their lives. Meals provided are of a good standard. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 12 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints process is in place enabling residents and relatives to raise their concerns with the management. Policies and procedures are in place to ensure the safety and well being of residents. EVIDENCE: There is a clear complaints procedure, which is included in the Statement of Purpose and Service User Guide. The records of complaints were reviewed. Residents spoken with confirmed they felt able to approach Mrs Curpen or her care team with any concerns they have. Staff have received training in Adult Protection procedures however a number of staff have since left. If staff have not received instruction in adult protection procedures as part of their induction another training session for them should be arranged. The two staff members spoken with at this visit were clear of the action they would take should they suspect that a resident is being abused, they were also aware of the types of abuse. There has been one adult protection investigation since the last inspection. The indicident was found to have been an accident that was reported by the staff member concerned at the time of the incident and records were kept. No further action was required. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 13 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): 19,26 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained. The standard of cleanliness through out the home was of a high standard. EVIDENCE: From touring the building the inspector noted that all private accommodation met the needs of the current service users. The home is well maintained. Individual aids and adaptations are provided as required, i.e. mobile hoists, wheelchairs etc. Rooms are individually decorated, residents can personalise their rooms with their own personal possessions, arm chairs, chest of drawers etc. It was noted that since the last inspection that new dining room furniture and chairs for the lounge have been purchased in line with the homes environmental improvement plan. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 14 All areas of the home were clean and free from offensive odours. Laundry facilities are appropriate to the size and current needs of residents. Policies and procedures are in place for control of infection. The home has a contract with a waste disposal company for the collection and disposal of clinical waste. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 15 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 quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are on duty in sufficient numbers to meet the needs of the current residents. A training programme is in place. The proprietors are working towards achieving 50 of care staff holding a National Vocational Qualification. The recruitment procedure has not been followed in full. EVIDENCE: Duty rotas record that there are generally 4 carers and one trained nurse during the morning, 3 are staff and 1 trained nurse in the afternoon and evening and 1 care and 1 trained nurse at night. Ancillary staff is on duty in sufficient numbers. The residents survey records that 5 residents confirmed that staff are available when you need them and 3 said that they are usually available. Fifteen care staff is employed in the home. Four of whom have obtained a National Vocational Qualification in cares level 2 or 3. This makes a total of 37 of care staff with a National Vocational Qualification. The training and development programme for 2006 records that Mr Curpen registered provider is undertaking the registered managers award and a further 6 carers are taking a National Vocational Qualification level 2 0r 3. Although this standard is not met in full a requirement has not been made as the providers are in the process of addressing this requirement. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 16 Staff were spoken with during the inspection they said that they felt that although Mrs Curpen is generally a kind person and that the home is well run they felt that there are times when she could discuss concerns with them in private and not in hearing distance of other staff and residents. Those spoken with confirmed that supervision has now started. There was evidence of in house induction being undertaken by new staff. It was confirmed that staff receive induction training in line with Skills for Care specifications, however there was not documentation to demonstrate this. A recruitment process is in place however, upon reviewing staff records it was noted that for one staff member the two references required were not on file and one was missing for another staff member. New employees must not start employment until all checks have been undertaken and evidence that the outcomes are satisfactory are in their personnel file. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 17 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): 31,33,35,38 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from being run by a manager who has a management qualification. The lack of a quality assurance and monitoring system makes it difficult to determine that the resident’s best interests are being maintained. Service users financial interests are safeguarded. The lack of fire safety training may put residents at risk of harm. EVIDENCE: Mrs Curpen is the registered manager, she is a Registered Nurse on part 1 of the register. She has also obtained the Registered Managers Award. Residents spoken with said that they feel able to talk with Mrs Curpen regarding any concerns they may have. One comment from the residents survey records that “Barnham Manor is a marvellous nursing home as it is family run: there is attention to detail as well as great tenderness, thoughtfulness and kindness. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 18 My farther is content and well cared for and after being here for 2 weeks decided that it was his home. Brenda and her husband are always on hand, courteous and helpful. Barnham Manor is a credit to them and their professional skills”. A policy and procedure regarding quality assurance and quality monitoring systems was submitted to the commission however thee was not evidence at this visit that a quality monitoring audit had taken place. The views of residents and other stakeholders must be sought. A quality assurance and monitoring system must be put in place to enable the providers determine that the needs and rights of residents are being maintained. A development plan should also be produced to evidence how and timescales by which any issues identified whilst undertaking the quality assurance system will be addressed. Residents manage their own finances, which was confirmed by residents. However, some money is held for resident on request so that they can pay for things such as hairdressing, small personal items and chiropody. Individual residents money is kept separate and records are kept of transactions made. Should a resident not wish to have money held in safe keeping there is a system in place whereby Mr Curpen can bill residents or their relatives each month. Information supplied on the pre inspection questionnaire records that regular servicing of boilers and equipment such as vertical lifts; boilers and electrical appliances are carried out. Systems are in place to ensure safe working practices such as manual handling, food hygiene and infection control however, records of fire safety training indicate that not all staff have received fire safety instruction at the recommended intervals of 6 monthly day staff and 3 monthly night staff. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 19 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 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP29 Regulation 19 13 (6) 24 Requirement References must be obtained prior to new employees commencing work. All staff must receive instruction in Adult Protection procedures. An annual quality assurance and quality monitoring system must be completed. This remains outstanding from the previous inspection. All staff must receive fire safety instruction at the recommended intervals of 6 monthly day staff and 3 monthly night staff. This was raised as a requirement at the last inspection. The requirement was met but has lapsed. Timescale for action 30/09/06 30/09/06 30/09/06 OP18 OP33 4 OP38 23 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 21 1 OP30 Records to demonstrate that staff receive induction training in line with skills for care specifications should be available. Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Barnham Manor DS0000039654.V301711.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!