CARE HOMES FOR OLDER PEOPLE
Barons Down Brighton Road Lewes East Sussex BN7 1ED Lead Inspector
Rebecca Shewan Unannounced Inspection 19th June 2006 09:40 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 DS0000013960.V290668.R01.S.doc Version 5.1 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 DS0000013960.V290668.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Barons Down 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 Mr Hadi Rajabali Mrs Shehnaz Rajabali Jane Susan Pitcher 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 DS0000013960.V290668.R01.S.doc Version 5.1 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 15th November 2005 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, providing accommodation on three floors, with eighteen single bedrooms with ensuite facilities, and three double bedrooms, which do not have ensuite facilities. There are additional toilets, shower rooms and bathrooms located throughout the home. A passenger lift serves all three floors. The home has a number of specialist equipment in use such as mobility aids, specialist nursing beds and bath and moving/handling hoists. All bedrooms are of a good size and have telephone points and lockable doors. There is a small patio area leading off from the lounge/ dining area that is accessible to service users. There are car-parking facilities to the front of the premises. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) are £500 - £780 per week, with additional charges made for newspapers, hairdressing and chiropody. NB: Fees vary according to the room occupied and the level of service user’s needs. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 19th June 2006. Incident reports, Monthly unannounced monitoring visit reports, previous inspection reports and the home’s Pre-Inspection Questionnaire, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took six and a quarter hours. A tour of the whole home was undertaken and the Registered Manager, two staff, four service users (known as Residents) and one relative/representative was spoken with. Records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Ten Service User Surveys were distributed of which three were returned. Comments received included: • • • ‘Al staff are very willing to listen to you and make sure your problems are solved’ ‘I like living here, the food is good and staff are friendly and helpful’ ‘The food is good but they always give me too much’ The Registered Provider was requested to complete a Pre-Inspection Questionnaire, which was returned in a timely manner. However, contact details for resident’s Care Managers, Social Workers and Placing Authorities had not been included in this documentation. Therefore, the views of these individuals/organisations have not been obtained for the purpose of this report. Twenty residents were accommodated at the home at the time of the inspection. What the service does well:
The home ensures that thorough pre- admission assessments are carried out on all new and potential residents with only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 6 There is an efficient complaints procedure in place and the homes procedures, processes should protect residents in the event of an allegation of abuse. The home has a staff team that have the necessary experience to the meet the needs of current residents. There is good maintenance of all staff recruitment files. What has improved since the last inspection? What they could do better:
The home must ensure that urgent action is taken to ensure that all handwritten entries onto medication Administration Record (MAR) sheets, are explained, signed and dated by the person making the entry, that the use of medication omission codes are explained on the back of the MAR sheets, use of non-administration codes must be consistent with those detailed on the MAR sheet, that all medications administered are signed for by the person who
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 7 administered them and that where missed entries have been highlighted on MAR sheets these are investigated and action taken, in order to ensure that residents are receiving essential medication and that records are maintained accurately to reflect this. Urgent action must also be taken to ensure that the health, safety and welfare of residents and staff are protected at all times in that Infection control procedures must be adhered to and clinical waste disposed of in the appropriate manner, that unnamed toiletries are such as shampoo, talcum powder and bubble bath are removed from the homes bathroom areas, that alcohol based hand lotion is removed from communal areas and stored in accordance with Control Of Substances Hazardous to Health (C.O.S.H.H) guidance and that residents wheelchairs are utilised in the appropriate manner with foot plates in use at all time. The home must ensure that some kitchen staff receive Food Hygiene training in order to reduce the risk of food associated hazards to both residents and staff. There is a need for the home to establish and implement a Quality Assurance policy and procedures in order to ensure that the views of residents, relatives/representatives and other interested parties are obtained and form part of the homes improvement plan. This is outstanding form the previous inspection. Care staff must also be formally supervised at least six times a year. This must be conducted to ensure that staff needs, training and other issues are monitored and appropriate actions taken to ensure that any areas of need are addressed. This is outstanding form the previous inspection. The home are also advised to ensure that residents and/or their representatives sign care plans, and where this is not practical it should be recorded, in order to provide evidence that residents and/or their representatives are actively involved in the care planning and review processes. The Statement of Purpose is in need of some minor amendments to ensure that it includes the size of the rooms in the home, thereby providing potential residents with the required information. An assessment of the home should be undertaken by a qualified Occupational Therapist to ensure that disability equipment and environmental adaptations are suitable for their purpose. The home are also advised to a minimum of 50 of care staff are trained to National Vocational Qualification (NVQ) level 2 in care and that the Registered Manager obtains an NVQ level 4 in management. These recommendations are outstanding from the previous inspection. 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. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 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 DS0000013960.V290668.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good processes for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: The home has made some minor improvements to the Service User Guide to ensure that resident’s comments are included. However, there remains a need for the home to amend the Statement of Purpose to include the size of bedrooms available. The home’s Registered Manager carries out pre- admission assessments. Records inspected showed that pre- admission assessments are carried out on all new and potential residents. It was noted that the documentation allows the assessor to gain a good overview of individuals medical, social and personal care needs. The home also obtains a copy of a care management assessment from a placing authority where this exists. Any issues, which are highlighted within this assessment, are addressed by the home and documented records are maintained of all correspondence with the placing authority.
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 10 Following the homes previous inspection on 15th November 2005, all staff have received training on how to care for service users with confusion and dementia. Staff records viewed confirmed this. Intermediate care is not offered by this home. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. However improvement is required to ensure that medication records are maintained appropriately in order to prevent the risk residents not receiving essential medications. EVIDENCE: Four residents individual care plans were viewed and it was noted that these were detailed in content and covered all aspects of resident’s needs. Residents informed the inspector that care plans are devised with their involvement. However, from the care plans sampled it was evidenced that neither residents/relatives/representatives signatures were recorded. Daily care records were also viewed and it was noted that many entries were signed but not dated, timed or the person’s designation recorded. Therefore a recommendation had been made. Suitable risk assessments were in place for the complications associated with reduced mobility, trip/falls hazards and associated risks. The home has access to a Tissue Viability Nurse who advises the home about pressure area sore prevention and maintenance of pressure
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 12 area sore dressings. This was evident from the residents spoken with and from the care plans viewed. From the records sampled and from discussions with staff it was evidenced that the health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. The Registered Manager said that residents have a choice of GP from one of four local surgeries. Resident’s are encouraged to attend the GP surgery were able and home visits are conducted when necessary. Referrals to the Occupational Therapist, Physiotherapist and Audiologist are made via the GP or the hospital. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home. However, the medication administration record (MAR) sheets were viewed and it was evidenced that some improvements are required, to address the manner in which staff record medications either administered or non- administered. It was evidenced that where medication had been omitted, the recording for the reason of this omission was not clearly recorded, with the code ‘O’ being recorded as ‘not required’ as opposed to an explanation being recorded onto the back of the MAR sheet. There were also some missed entries noted, in particular a resident’s eye medication making it difficult to determine whether this medication had been administered or not. It was also evidenced that where medications such as creams/lotion/ointments have been prescribed, entries onto MAR sheets are not completed. All medications administered must be signed for by the person who has administered the treatment. Some handwritten entries were also noted and it was evidenced that these were unsigned, undated and that no explanation had been given on the back of the MAR sheet. Records for the daily monitoring of fridge temperatures were also viewed and these were noted to be maintained in a poor manner, although the fridge was empty records must be maintained on a daily basis to ensure that new medications that require refrigeration are stored in a well maintained and working fridge. Therefore Immediate Statutory Requirements were made. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Of the three service user surveys received one stated that they always received the care and support that they needed, whilst one responded that they usually received the care and support that they needed. The third had been left blank. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a balanced diet to residents, with residents choice and wishes being respected. EVIDENCE: The home does not have a published list of weekly activities. The Registered Manager said that this had been in place but that resident’s attendance to activities was low and that residents had said that too much was on offer. Therefore resident activities are now arranged and altered according to resident’s requests. Residents are free to participate in activities, held by the home or within the local community, or not as they wish. One resident spoke of how much they enjoyed a recent picnic, which they had with their family. Of the three service user surveys received one responded always and two responded sometimes to the question that asks ‘are there activities arranged by the home that you can take part in?’. One resident commented that they would like to have ‘chair exercises to prevent stiffness’. Family contact is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Resident’s religious wishes are observed and arrangements are in place for residents to receive non-denominational Holy Communion if they wish. Discussions with the
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 14 Registered Manager highlighted that although many of the current residents fall into a specific age group and have similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The home assists residents with maintaining independence in their daily living and daily routines, where able. Residents are treated with respect and there is a good rapport between staff of the home and residents. This was observed at the time of the inspection. The home’s menus are devised on a four week rolling programme. The menus viewed showed that there is a variety of food and that the menus are varied. In order to assist residents with meal selection the home has devised picture menus so that residents can see the menu options. All meals are home cooked with an alternative option available for each mealtime. Medical, therapeutic or religious diets are provided as needed. Of the three service user surveys received one responded always and two responded usually to the question that asks ‘Do you like the meals at the home?’. Relatives spoken with informed the Inspector that the food served for their relative is always attractively presented, although it is pureed. One residents said that the food is ‘so lovely that if I wasn’t full from the first portion I’d ask for seconds’, whilst another resident said that ‘meals served are too large in amount and I hate to waste so much food’. The homes Chef confirmed that she has had many discussions with residents about meal size and that it hasn’t been reported as a problem for sometime now. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. From the section in the service user surveys received relating to complaints, this showed that the three resident’s always felt listened to and one felt that they always knew who to speak to in the event of a complaint/concern, whilst two responded that they usually know who to speak with. The home has received five complaints within the past twelve months, all which have been recorded as addressed within the twenty-eight day response time as specified by the home’s policies and procedures. Each of the five complaints have now been resolved and appropriate action was taken by the home to address the concerns raised. Verification of nursing staff’s registration to practice is obtained from the Nursing and Midwifery Council (NMC) prior to nursing staff commencing employment. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. The home has a
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 16 copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides a good quality of accommodation for residents that is safe, hygienic and odour free, with some improvement required to ensure that infection control procedures are adhered to at all times, thereby reducing the risk of cross infection to staff and residents. EVIDENCE: The home is generally well maintained and all areas of the home, including the garden, are accessible to residents. Of the three service user surveys received one responded always and two responded usually to the question that asks ‘Is the home fresh and clean?’. Following the inspection of the home in November 2005 the home has made the required improvements to ensure that a programme of routine maintenance and renewal of the fabric and decoration of the premises be produced and sent to the Commission, which included the replacement of beds and other nursing equipment and that all the furniture in the home is reviewed to ensure that it is appropriate and safe. It was noted
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 18 during the tour of the premises that some bedrooms had been newly decorated and that new chairs and beds had been obtained by the home. However a previous inspection recommendation that an assessment of the premises and facilities should be undertaken by a qualified Occupational Therapist (OT), to advise on the suitability of disability equipment and environmental adaptations has not been conducted. The Registered Manager said that the home were in the process of obtaining the services of an OT assessment, however this was not proving to be as easy as she had an anticipated due to the time constraints of the OT department sourced. The home was odour free throughout. The home has an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records and by staff spoken with. However, there is a need for the home to ensure that infection control procedures are adhered to at all times, as it was noted that a pair of used disposable gloves were on the floor of one of the homes bathroom areas. Therefore an immediate requirement was made at the time of the inspection. It was evidenced that a clinical waste contract is in place. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 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 area is good. This judgement has been made using the available evidence including a visit to this service. The home an effective recruitment procedure in place ensuring that only appropriate staff are employed by the home, however there is a need for the home to ensure that some staff receive appropriate training that is specific to their job in order to reduce the risk of hazard to residents. EVIDENCE: A competent staff team meets the resident’s needs. There is a staff rota in place, which was made available to the inspector with the home’s preinspection questionnaire and it was noted that this did not specify the capacity in which staff were employed. Therefore a recommendation has been made. Of the three service user surveys received two responded always and one responded usually to the question that asks ‘Are the staff available when you need them?’. The Registered Manager acknowledged that staff numbers and skills had been varied over the past few months and that a high number of agency staff had been utilised by the home and that following the successful recruitment of two Registered Nurses, permanent staff numbers should improve within the next month. However, an evening chef/kitchen assistant is not provided so this means that one of the care staff has to complete catering duties reducing the time available for care. The Registered Manager said that the home had been experiencing some difficulties in recruiting a suitable person into this role, but that the home were still actively trying to recruit a person for this position.
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 20 The home has a permanent care staff team of six carers, two of which are currently undertaking the National Vocational Qualification (NVQ) level 2, in care, course. The Registered Manager reported that a further three care staff are due to commence NVQ training in the near future. This was confirmed in the homes Pre-Inspection Questionnaire and from staff training records viewed. Staff confirmed that the home is committed to staff achieving NVQ’s in care. Therefore the previous inspection recommendation that a minimum ratio of 50 of care staff have achieved a NVQ in care by 2005 remains unmet. Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001.The home has an Equal Opportunities policy in place and is an equal opportunities. Following the previous inspection of November 2005 the home has made significant progress to ensure that staff are provided with appropriate training to equip them fully to care for residents and to work safely. Staff training records showed that over the last seven months the home had provided a range of training, including Induction Training, Medication Training, Fire Training, Health and Safety, Moving & Handling, and Infection Control. Other training related to the needs of the resident’s such as Caring for People With Dementia and Diabetes has also been undertaken. However, a Kitchen Assistant spoken with confirmed that they had never had any Food Hygiene training. Therefore a requirement has been made. A Registered Nurse spoken with at the time of the inspection said that they felt the training provided was good and provided them with the opportunity to achieve their Post Registration Education and Practice (PREP) requirements, as governed by the NMC. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 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, 36 & 38 Quality in this area is poor. This judgement has been made using the available evidence including a visit to this service. The management and administration of the home requires improving to ensure that appropriate Quality Assurance procedures are implemented in order to ensure that evidence of consideration being given to residents choice and opinion in the operation of the home and to ensure that staff are formally supervised. There is also some improvement required to ensure that the health, safety and welfare of residents and staff is protected at all times. EVIDENCE: The Registered Manager has many years relevant experience in caring for older people with nursing care needs. The Registered Manager is a qualified Registered Nurse and is currently undertaking the Registered Managers Award, which she aims to complete by the End of July 2006. Therefore the previous inspection recommendation that the manager obtains NVQ Level 4 in Management or its equivalent by 2005, remains unmet. Residents and staff
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 22 spoken with said that the Registered Manager is friendly, approachable and actions any issues raised quickly and efficiently. The home does not have a formal Quality Assurance policy in place. The home conducted an annual questionnaire last year, the results of which are now published and are available in the homes Statement of Purpose. However, the Registered Manager reported that this questionnaire was very basic in content and that she is currently devising a new one to be more service specific. The Registered Manager reported that she meets with residents on a daily basis and actions are taken to address any areas of concern highlighted. However, formal resident meetings are not conducted and minutes or records of the manager’s discussions with residents are not maintained. Therefore the previous inspection requirement that a full quality assurance system is established and used to maintain and improve the provision of care and services in the home has not been met. Staff meetings are held two to three times a year and on a required basis. Minutes of Staff meetings were viewed and these were found to be detailed in content and included actions taken to address previous issues raised by staff. Monthly unannounced (Regulation 26) visit reports are conducted and a copy of this report is sent to the CSCI Eastbourne Office. The homes policies and procedures have now been reviewed and updated accordingly. Therefore the previous inspection requirements that the registered provider visits the home in accordance with Regulation 26 and that all the homes policies are reviewed and updated to underpin best practice have now been met in full. The Registered Manager reported that the home does not take any responsibility for resident’s finances. Following the previous inspection of November 2005 the home has not met the requirement that a formal process of documented supervision is implemented and provided to care staff at least six times a year. The Registered Manager reported that informal supervision of care staff occurs but that written records are not maintained and that these supervisions are not conducted on a regular basis. Therefore there is a need for the home to implement this. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. Accidents are well documented in the home’s accident book. Fridge, freezer and food temperature probe readings are recorded on a daily basis. During the tour of the premises it was noted that care staff were mobilising one resident in their wheelchair without footplates in place, presenting an increased risk of hazard to the resident. It was also evidenced that in some of the homes bathroom areas there were unnamed toiletries such as shampoo, talcum powder and bubble bath, which could be deemed for use communally and presenting a risk to residents of hazard and/or cross infection. It was evident that the home encourage staff to utilise an alcohol based hand lotion which is marked as ‘toxic’ and ‘irritant’,
Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 23 however bottles of lotion were freely accessible to both residents and staff and were not maintained in accordance with Control Of Substances Hazardous to Health (C.O.S.H.H) thereby increasing the risk of hazard to both residents and staff. Therefore Immediate Statutory Requirements were made relating to these issues. Please note that prior to this report being published the home has ensured that all care staff are now in receipt of pocket sized hand lotion. Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 24 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 3 x x 3 x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x N/A 2 x 1 Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 25 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 OP7 Regulation 15(1)(2)c Requirement That care plans are drawn up in consultation with residents or their representatives as appropriate and are reviewed regularly. This is outstanding from the two previous inspections. That the use of medication omission codes are explained on the back of the MAR sheet. This is an immediate requirement. That all medications administered, in particular lotions/creams/ointments, are signed for by the person who administered them. This is an immediate requirement. Timescale for action 19/08/06 2. OP9 13 (2) 19/06/06 3. OP9 13 (2) 19/06/06 4. OP9 13 (2) That where missed entries have 19/06/06 been highlighted on MAR sheets, these are investigated and action taken to ensure that all residents are receiving essential medication. This is an immediate requirement. That all handwritten entries onto
DS0000013960.V290668.R01.S.doc 5. OP9 13 (2) 19/06/06
Page 26 Barons Down Version 5.1 medication Administration Record (MAR) sheets, are explained, signed and dated by the person making the entry. This is an immediate requirement. 6. OP26 13 (3) That infection control procedures are adhered to at all times in that clinical waste in disposed of in the appropriate manner. This is an immediate requirement. That one of the home’s kitchen assistants attends Food Hygiene training. That a full quality assurance system is established and used to maintain and improve the provision of care and services in the home. This is outstanding from the previous inspection. That a formal process of documented supervision is implemented, and provided to care staff at least six times a year. This is outstanding from the previous two inspections. 19/06/06 7. 8. OP30 OP33 18 (2) 24(1) 19/09/06 19/09/06 9. OP36 18(2) 19/09/06 10. OP38 12 (1) (a) (b) & 13 (4) (a) (b) (c) 13 (4) (a) (c) 11. OP38 12. OP38 13 (4) (a) (c) That resident’s wheelchairs are 19/06/06 appropriately maintained and footplates are in use at all times. This is an immediate requirement. That alcohol based hand lotion, 19/06/06 which is labelled as ‘toxic’ and ‘irritant’ must be removed from all communal areas and stored in accordance with C.O.S.H.H guidance. This is an immediate requirement. That unnamed products such as 19/06/06 shampoo, talcum powder and bubble bath are removed from the homes bathroom areas. This is an immediate requirement.
DS0000013960.V290668.R01.S.doc Version 5.1 Page 27 Barons Down RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP1 OP7 OP7 OP22 Good Practice Recommendations That the statement of purpose includes the size of the rooms in the home. This is outstanding from the previous inspection. That residents and/or their representative sign care plans and that where this is not practical, care plans reflect this. That staff who make entries onto residents daily care records, record the date, time and their job designation on each entry made. That an assessment of the premises and facilities should be undertaken by a qualified Occupational Therapist, to advise on the suitability of disability equipment and environmental adaptations. This is outstanding from the previous inspection. That a minimum ratio of 50 of care staff have achieved a NVQ in care by 2005. This is outstanding from the previous inspection. That the manager obtains NVQ Level 4 in Management or its equivalent by 2005. This is outstanding from the previous inspection. 3. 4. OP28 OP31 Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Barons Down DS0000013960.V290668.R01.S.doc Version 5.1 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!
