Inspection on 14/05/08 for Barons Down Nursing Home

This inspection was carried out on 14th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Barons Down Nursing Home 28/04/09

Barons Down Nursing Home 22/06/07

Barons Down Nursing Home 19/06/06

Barons Down Nursing Home 15/11/05

Barons Down Nursing Home 21/06/05

Barons Down Nursing Home 13/10/04

Barons Down Nursing Home 10/05/04

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Barons Down Nursing Home Brighton Road Lewes East Sussex BN7 1ED Lead Inspector Jennie Williams Unannounced Inspection 14th May 2008 10:15 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 Barons Down Nursing Home DS0000013960.V361052.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. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barons Down Nursing Home Address Brighton Road Lewes East Sussex BN7 1ED 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) 01273-472357 01273 479104 brooklandsnursinghome@yahoo.co.uk Mr Hadi Rajabali Mrs Shehnaz Rajabali VACANT Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (24) of places Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty four (24). That the care home provides general nursing care to older people aged sixty five or older on admission. That the service users may also have a physical disability. Date of last inspection 22nd June 2007 Brief Description of the Service: Barons Down is registered to provide nursing care for twenty-four service users, who are over 65 years of age and may also have a physical disability. The home is purpose built and is located in a quiet residential area on the outskirts of Lewes. Local amenities can be found within walking distance of the home and there is nearby access to public bus routes. Free car parking is available at the home. Rooms are located over three floors, all of which are served by a passenger shaft lift. Eighteen rooms are for single occupancy of which all have en suite facilities. There are three double rooms that do not have en suite facilities. There are additional toilets and bathrooms located throughout the home. The home has a number of specialist equipment in use such as mobility aids, adjustable nursing beds and moving/handling hoists. There is a small patio area leading off from the lounge/ dining area that is accessible to service users. Weekly fees range between £550 and £850. There are additional fees; hairdressing, Chiropody, newspapers/magazines and personal toiletries (at cost). This information was provided to the CSCI on the 16 June 2008. Prospective residents find out about the service through social services referrals, word of mouth and from living in the area. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. It was confirmed to the Inspector that people who use this service are called residents. For the purpose of this report, people who use the service will be referred to as residents. There is no Registered Manager at this service. A person appointed by the Registered Provider to be in charge of the home commenced employment in August 2006. For the purpose of this report they will be referred to as the appointed manager. This unannounced key site visit was undertaken on the 14 May 2008 over a period of seven hours. Verbal feedback was provided to the appointed manager the day after the site visit. Evidence obtained at this site visit and information that the CSCI have received since the last key inspection forms this inspection report. Five residents were spoken with throughout the site visit. The Inspector had limited verbal communication with some residents due to their level of needs. Specific areas of care were viewed in seven care plans. The Inspector had contact with two visitors at the home. The appointed manager and three staff were spoken with throughout the site visit. Three staff files were viewed, along with a variety of training records. A tour of the environment was undertaken and some individual rooms were viewed. Systems for the administration of medication were inspected and the quality assurance and quality monitoring system in place was discussed and the most recent results were viewed. An Annual Quality Assurance Assessment (AQAA) was received from the home prior to the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. The information contained in this was brief. There were seventeen residents residing at the home on the day of the site visit and one resident was being admitted. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 7 All windows, where identified as being required, must be restricted to ensure residents are safeguarded. This will also assist in keeping unwanted intruders being able to access the home. Robust recruitment procedures must be followed to ensure residents are safeguarded. Evidence of all checks must be available for inspection. It has now been made a requirement that an application is forwarded to the CSCI in relation to the manager’s post to ensure that the person managing the service is not in breach of the regulations. Regulation 26 reports must be completed, shared with the manager and be available at the home for inspection. These monthly visits, resulting in a report, will assist the registered provider to monitor their service and ensure that the home is being run in a way that meets the aims and objectives and assists in identifying areas for improvement. Other minor shortfalls noted, which have not been reflected as a requirement or recommendation have been noted throughout the inspection report. 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. The summary of this inspection report can be made available in other formats on request. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. EVIDENCE: The home has information available to prospective residents/representatives regarding the services and facilities provided at the home. Information regarding room sizes are now reflected in these documents as previously recommended. The appointed manager confirmed that she takes these documents with her when assessing any prospective resident, however confirmed that no one has requested a copy. It is recommended that these documents be left with prospective residents/representatives so they are able Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 10 to read the information at their leisure and be in a better position to made an informed decision if the home can meet their needs and expectations. The appointed manager undertakes an assessment of prospective residents prior to admission. Information is obtained from other health professionals wherever applicable. The pre admission process ensures that only those residents whose needs can be met are accommodated at the home. Staff spoken with confirmed that management take appropriate action if a residents needs change and can no longer be met with the services and facilities the home provides. The appointed manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. Prospective residents are encouraged to visit the home prior to moving in. A resident spoken with confirmed that they were unable to visit the home prior to moving in, however their family came to visit. They confirmed that someone from the home came to visit them in hospital and undertake an assessment. The individual confirmed that they were happy with the admissions process and the welcoming they received was pleasing and enough. It is stated in the terms and conditions of residency that the first month is considered as a trial period. The home does not have dedicated accommodation to provide intermediate care, however respite is available if there is a spare place. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. Residents are safeguarded by the medication procedures in place. Residents’ privacy and dignity are respected. EVIDENCE: Care plans were not viewed in detail at this site visit, as there were no shortfalls noted at the last inspection and the appointed manager confirmed that the format and reviewing process has not changed since the last inspection. It was confirmed that care plans are initially drawn up with the individuals and if changes are made at the monthly reviews, this is discussed with the resident. A resident confirmed that staff discuss their care with them. Staff spoken with confirmed that they find the care plan format user friendly and informative. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 12 There is a key worker system at the home that the appointed manager confirmed worked well, however on discussion with one resident, they were unaware of who their key worker was. On viewing daily notes, it was observed that staff were writing ‘all care as per care plan’. Daily records are a good source of evidence to show that care is being provided, as detailed in the care plan, however the term All care given is not helpful or adequate. Daily records when well written, help ensure a consistent approach and good quality of care for residents. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. It is recommended that nurses read the guidelines on record keeping provided by the Nursing and Midwifery Council (NMC). Specific areas of care were viewed and it was observed that clear guidance was in place for staff on how to meet the needs of the individual. On speaking with a resident, they identified that they did not have their glasses on or their hearing aid in. Staff were quick to respond to their request. It was observed that there was no guidance in the care plan for staff regarding these additional aids that are important for the individual. When providing feedback to the appointed manager, she confirmed that this information had already been included into the care plan. Residents have access to other health professionals. Specialist advice is sought when needed such as a dietician and tissue viability nurse. Residents and visitors spoken with confirmed that they felt all their needs were being met at the home and were happy with the care being provided. Medication Administration Records (MAR) charts viewed demonstrated that medicines are signed for at the time of administration. Hand written prescriptions are being double signed as recommended at the last inspection to further safeguard residents and staff from errors occurring. It is recommended that where it is prescribed one or two tablets, it is recorded how many are administered to ensure clear records are maintained. This practice was observed not to be consistent throughout the MAR charts. The home has recently changed their supplying pharmacist and medicines are now provided in individual blister packs and supplied on a weekly basis. Records are maintained of incoming and outgoing medicines and the appointed manager confirmed that medicines are being disposed off through a licensed company. The appointed manager confirmed that there are policies and procedures in place for all aspects of dealing with medication. These were not read. There is currently no controlled drugs being used or stored at the home. Residents are provided with an opportunity to self medicate if they wish and a risk assessment identifies it is safe for them to do so. There was no one selfmedicating at the time of the site visit. It was confirmed creams/lotions Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 13 prescribed are reflected in care plans and are being signed for when administered. Residents spoken with felt that staff respect their privacy and dignity. It was observed on the day of the site visit that staff have a good professional rapport with residents and were heard to be calling them by their preferred term of address. Staff were observed to knock on individual room doors prior to entering. Barons Down Nursing Home DS0000013960.V361052.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is generally their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Residents are provided with varied nutritional meals and are provided with choice to ensure their preferences are catered for. EVIDENCE: Residents spoken with confirmed that there were sufficient activities provided at the home if they choose to be involved. Some residents confirmed that they prefer to remain in their rooms. Staff confirmed that they felt the provision of activities has improved and they have more time to spend one to one time with individuals. Records are maintained of who participates in activities. The home does not have a mini bus and some residents are not provided with an opportunity to go out into the community. It was discussed with the appointed manager that consideration be made to take residents out of the home environment, particularly when the weather is suitable. No requirement or recommendation has been made in relation to this, however the appointed Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 15 manager must ascertain the wishes of the residents and take action if identified. Some residents are supported by family/friends to visit places within the community. Residents spoken with confirmed that they are able to generally choose their own daily routines. Residents were observed to move freely within the home on the day of the site visit. Residents spoke positively about the food provided at the home and are provided with a choice to ensure preferences are accounted for. Since the last inspection, the routines for meals have been changed, ensuring that all residents receive individual assistance and all meals remain warm. Those requiring assistance are provided with meals half an hour before everyone else so that maximum numbers of staff are available to assist residents. Staff spoken with felt that there has been positive changes with the meals provided. Barons Down Nursing Home DS0000013960.V361052.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Safeguarding Adult procedures and the training of staff ensure residents are safeguarded. EVIDENCE: There is a complaints procedure available at the home and of those residents who were asked, all confirmed that they know who to speak to and would feel comfortable raising any concerns. A record of all complaints has been commenced as required at the last inspection. The AQAA identified that there have been 14 complaints made in the last 12 months of which none were upheld. On viewing records, it was evident that minor concerns are taken seriously and actioned wherever identified as being needed. The appointed manager confirmed that all staff have undertaken basic Safeguarding Adults training and six to eight staff have done this training more in depth. She confirmed that not all senior staff that may be left in charge of the home has done this training. On discussion with staff, they identified that they were familiar with the procedures to take in the event of an allegation being made. The appointed manager has recently undertaken a Safeguarding Adults ‘Train the trainer’ course to enable her to train the staff in Safeguarding Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 17 Adults procedures. She confirmed that following this training she reviewed the home policies and procedures. The whistle blowing policy and procedure needs to be amended to identify that it is the registered persons responsibility to refer individuals to Protection of Vulnerable Adults (POVA) and not the CSCI as currently stated. It is recommended that telephone numbers are provided in this procedure to advise staff on various authorities they can contact should they not want to raise the issue with people within the home. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment and are provided with comfortable indoor communal facilities. EVIDENCE: Three rooms are used for double occupancy and all other rooms are for single occupancy. Rooms are located over three floors and there is a passenger shaft lift available to assist residents to access all areas of the home. En suite facilities are not provided in the shared rooms and all single rooms are provided with en suite facilities. Two rooms have a shower in the en suite, however people must be able to mobilise to use these facilities. These are showers that individuals must step into. Some individual rooms were seen to be personalised to reflect individual’s choice and character. Of the residents Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 19 that were asked, all confirmed that they were happy with their individual rooms. On touring the environment, some minor shortfalls were noted that the appointed manager confirmed that she would address. Attention needs to be made to ensure that under the bath hoist seats are kept clean. It was confirmed that window restrictors are in place, however it was observed at the site visit that some had been overridden. Should they be overridden, risk assessments must be in place to ensure residents are safeguarded. Consideration must be made to restricting all windows to assist in ensuring unwanted people cannot enter the premise. Staff need ensure they leave a residents call bell within reach at all times, unless documentation evidences why an individual is not provided with one. It was observed that toilet rolls were being sat on top of the cistern in some areas. This will pose difficulties for those residents who may be unable to reach these and therefore poses a risk to their independence not being promoted and maintained. Toilet roll holder must be used. Some of the furniture in the communal areas needs to be thoroughly cleaned or replaced. Some chairs are starting to look old and worn/dirty. Some hoists were noted to be stored in a communal bathroom. The appointed manager confirmed that no one residing within this vicinity is able to use the toilet independently. The staff must keep the appropriate storage of this equipment under review to ensure that residents are able to access this toilet independently if needed. The appointed manager confirmed that there is a rolling programme for the redecoration of rooms within the service. Not all beds provided are adjustable, as recommended for those in receipt of nursing care, however the appointed manager confirmed that the home accesses adjustable beds when the need arises. The AQAA identifies that there is a policy in place for preventing infection and managing infection control. Sixteen staff have received training on the prevention of infection and management of infection control. The home was free from offensive odours on the day of the site visit. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty. Following robust recruitment procedures will better safeguard residents. EVIDENCE: Staff and residents spoken with confirmed that there are sufficient numbers of staff on duty to meet the needs of the residents. Staff were observed to have a good professional rapport with residents. Residents generally spoke positively about the staff at the home. The AQAA identifies that 57 nursing shifts and 1 care shift has been covered by temporary staff or staff from an agency within the past three months. It was confirmed that the same agency staff is used to ensure continuity of care is provided to the residents. It was confirmed that there are usually four carers working in the morning, three in the afternoon and one at night. There is always a registered nurse on duty. Staff files viewed identified that more robust recruitment procedures must be implemented. References had not been obtained for one staff member and there was no copy of this person’s visa to evidence that they are eligible to Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 21 work in the UK. Other visas’ on file were out of date, however the appointed manager confirmed that these people are still eligible to work in the UK. The appointed manager was advised to contact the home office to obtain information if there are restrictions to working, including the number of hours a person can work, in relation to the student visas that were present. The home obtains a copy of the nurses Personal Identification Number (PIN) from the individuals. Confirmation of valid registration must be obtained from the Nursing and Midwifery Council (NMC) for all registered nurses. This was identified the appointed manager at the last inspection. Criminal Record Bureau (CRB) checks were not available for viewing at the home. The registered provider confirmed via e-mail to the Inspector following the inspection that all staff have had a CRB check undertaken. Evidence that staff have had an enhanced CRB check must be maintained at the home. The AQAA identifies that eight of the ten care staff employed have National Vocation Qualification (NVQ) level 2 or above. Mandatory training is out of date for some of the staff. No requirement has been made in relation to this as the appointed manager confirmed that she is aware of this and is taking action to address this shortfall. Staff spoken with confirmed that they felt there were enough training opportunities provided. The appointed manager confirmed via telephone that she has been provided with information in relation to the Common Induction Standards as set by Skills for Care. She must ensure that this induction is implemented. Staff files evidenced that new staff had undertaken an in house induction. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents, however further work on monitoring the service will assist in evidencing that the home meets its aims and objectives. EVIDENCE: The person appointed by the registered providers to manage the home has been in post since August 2006. She is a registered nurse who confirmed that she has current registration with the NMC. Priority must be given to ensuring the CSCI receive an application to process in respect of her registration. This has been an ongoing issue and the registered provider confirmed to the Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 23 Inspector via telephone following the site visit that an application is being forwarded. The appointed manager is a registered nurse with current registration with the NMC and is nearing completion of National Vocation Qualification (NVQ) level 4 in management. Staff spoken with confirmed that they find the acting manager supportive and approachable and is open to trying out new ideas staff may suggest. The appointed manager has commenced implementing a quality assurance and quality monitoring system to ensure that the home is run in the best interest of residents. Feedback is sought from relatives/representative and staff. The appointed manager confirmed that she will be obtaining feedback from visiting health professionals. It was discussed with the appointed manager that results of these surveys are analysed and made available to residents and other stakeholders who have an interest within the home. The appointed manager confirmed that she reads these results and takes action if identified as being needed. Discussions were had with the appointed manager on ways to improve the information provided within the AQAA. The appointed manager confirmed that this document arrived whilst she was on holiday and was provided with limited time to complete. The information contained in this document was reflective of the short time used to complete this document. The person completing this form must read the guidelines provided and ensure that at least the key standards are addressed. There were no Regulation 26 reports available for viewing at the home. The appointed manager confirmed that a registered provider does visit the home on a regular basis, however no feedback is provided to the appointed manager, either verbally or written. This has been made a requirement. The home does not hold personal allowances for residents. Residents have their own measures in place for the handling of their money. The AQAA identifies that equipment in use has been serviced or tested as recommended by the manufacturer or other regulatory body. The appointed manager confirmed that she will include the checking of the suctioning machine into the programme of health and safety checks that are regularly undertaken. Any shortfalls identified that may pose a risk to residents’ health, safety and welfare have been highlighted in the relevant sections of the report. It was confirmed that the appointed manager and all staff who may be left in charge of the home in her absence have familiarised themselves with the homes fire risk assessment as required at the last inspection. It was Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 24 confirmed that any shortfalls identified in the risk assessment have been addressed, ensuring the safety of all people within the home is promoted. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19 Schedule 2 8&9 26 Requirement Timescale for action 30/06/08 2. 3. OP31 OP33 4. OP38 13(4) That robust recruitment procedures are followed to ensure service users are safeguarded. That an application is forwarded 15/07/08 to the CSCI to process in respect of a registered manager. That regulation 26 reports are 31/07/08 completed and shared with the manager to assist them in ensuring that the aims and objectives of the home are being met and identify areas of improvement. These reports must be available for inspection at the home. That all windows, where 30/06/08 required, are restricted to ensure service users are safeguarded. 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 Good Practice Recommendations DS0000013960.V361052.R01.S.doc Version 5.2 Page 27 Barons Down Nursing Home 1. Standard OP9 Where it is prescribed one or two tablets, it is recorded how many are administered to ensure clear records are maintained. Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Barons Down Nursing Home DS0000013960.V361052.R01.S.doc Version 5.2 Page 29 - 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!