CARE HOMES FOR OLDER PEOPLE
Barons Down Brighton Road Lewes East Sussex BN7 1ED Lead Inspector
Jennie Williams Key Unannounced Inspection Key 22nd June 2007 11:00 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.V338853.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 DS0000013960.V338853.R01.S.doc Version 5.2 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 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 DS0000013960.V338853.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 19th June 2006 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, specialist nursing beds and bath 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 £785. There are additional fees; hairdressing, Chiropody, newspapers/magazines and personal toiletries (at cost). This information was provided to the CSCI on the 22nd June 2007. Prospective residents find out about the service through social services referrals, word of mouth and from living in the area. Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. 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. A person appointed by the Registered Person to be in charge of the home commenced employment in August 2006. For the purpose of this report they will be referred to as acting manager. This unannounced key site visit was undertaken on the 22 June 2007 over a period of six hours. The information contained in this report has been comprised from this site visit and information gathered about the home prior to the inspection. Eight residents, of both genders and over the age of sixty-five years, were spoken with throughout the site visit. The Inspector had limited verbal communication with some residents due to their level of needs. One residents care plan was viewed and specific areas of care were looked at in other care plans. The Inspector had contact with three visitors of the home. The acting manager and two staff were spoken with throughout the site visit. Three staff files were viewed and the provision of training was discussed with the acting manager. The environment was briefly observed and some individual rooms were looked at. Systems for the administration of medication were inspected and the quality assurance and quality monitoring system in place discussed. The Inspector joined the residents for lunch. An Annual Quality Assurance Assessment (AQAA) was received from the home after the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. There were twenty residents residing at the home on the day of the site visit. What the service does well:
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. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 6 their needs. The pre admission process ensures that only those residents whose needs can be met at the home are admitted. Care plans provide guidance to staff on how to meet the assessed needs of residents. Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Residents felt that their privacy and dignity are respected. Routines of daily living are generally to the individual’s choice and preference. Activities are provided at the home that is within an individual’s choice, interest and ability. Visitors are welcomed at the home and residents may receive visitors in private. Residents found their rooms to be comfortable and the home was free from offensive odours. There are suitable communal facilities provided to meet the needs of residents residing at the home. Residents’ needs are being met with the number and skill mix of staff on duty and are generally safeguarded by the recruitment procedures in place. Residents are encouraged to control their own money or make other arrangements with friends/family. The home does not hold money for individuals. What has improved since the last inspection?
Nine of the twelve requirements made at the last inspection have been fully met. Action has been commenced to address a further two. Residents/representatives are now involved in the drawing up and reviewing process of their care plans to ensure choice and preferences can be taken into account wherever applicable. The recording processes for the administration/omission of medicines have improved to ensure residents and staff are safeguarded. It was previously required that medication administered, in particular creams/lotions are signed for by the person who administers them. The acting manager is currently in discussion with staff and other health professionals regarding the use of creams, prescribed and non-prescribed. Infection control procedures have been reiterated to staff and all rooms have gloves in them to ensure easy access for staff and the AQAA identifies that there are policies and procedures in place for the disposal of clinical waste. All staff that handle food has received food and hygiene training. This action taken by the home as required will ensure that residents and staff are protected from spreading of infections. Supervision has just commenced for staff and records are kept of these sessions. This had been outstanding for the last three inspections. This will assist in management monitoring the training needs of staff and ensure that the homes aims and objectives continue to be met.
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 7 All three requirements made in relation to health and safety matters have been complied with. This included: ensuring wheelchairs are appropriately maintained and foot plates are being used, alcohol based hand lotions have been removed from communal areas and all Control of Substances Hazardous to Health (COSHH) substances are stored in accordance with COSHH guidelines and all unnamed items found in communal bathrooms have been removed. Action taken in relation to these requirements ensure that the residents and staff health, safety and welfare is promoted and protected so far as is reasonably practicable. Any recommendations made at the last inspection have been taken into account and actioned where necessary. These included: having the premise assessed by an Occupational Therapist, ensuring staff undertake National Vocation Qualification training and involving having residents/representatives sign their care plans. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request.
Barons Down DS0000013960.V338853.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 DS0000013960.V338853.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): 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. The room sizes are not currently identified in these documents as previously recommended. Room sizes have been obtained and the acting manager confirmed that this information will be included into the Statement of Purpose and Service Users Guide. The acting manager undertakes an assessment of prospective residents prior to admission. Information is obtained from other health professionals
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 10 wherever applicable. The pre admission process ensures that only those residents whose needs can be met are accommodated at the home. A staff member 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 acting 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. Most of the residents spoken with confirmed that they or a representative visited the home prior to them moving in. 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 DS0000013960.V338853.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): 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: The care plan viewed provided guidance to staff on action to take to meet the needs of individuals. There was evidence that care plans are being reviewed on a monthly basis. Specific areas of care were noted to be reflected in other individual care plans. Staff write any changes on the care plans as the needs of individuals may change and the acting manager confirmed that every month she will retype the care plans to reflect all updates. The acting manager confirmed that she reviews the care plans with the residents wherever possible. She has implemented a new form to obtain the signature of the residents/representative involved in the review.
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 12 A visiting GP was spoken to during the site visit who confirmed that she has a good rapport with the home and is called out to visit residents appropriately. There were no concerns expressed by the GP regarding care practices within the home. A resident was being assisted to attend an outpatient’s appointment on the day of the site visit. Residents spoken with confirmed that they felt that their needs were being met at the home. A resident observed to be wearing glasses confirmed that optician appointments are arranged when required/requested and that they have access to hearing and dental services. Specialist advice is sought when needed. Residents are weighed monthly and it was confirmed that any necessary action is taken if the need arises. A registered nurse confirmed that a physiotherapist visits a resident on a regular basis. A communication aid was observed to be in place for a resident who had special communication needs. This resident has resided at the home for a period of time and staff are familiar with this individuals communication methods. Two visitors spoken with confirmed that they are happy with the care provided at the home and found it a relief that their friend/relative is living in a home where they are well looked after. It was noted that all care staff at the home are females. Male residents spoken with confirmed that they do not mind being provided personal care by female carers. Risk assessments were observed to be in place for individuals. The acting manager confirmed that risk assessments are reviewed along with the care plans on a monthly basis. Medication Administration Records (MAR) charts viewed demonstrated that medication is being signed for at the time of administration. The home uses individual blister packs when administering medication. Accurate records were observed to be maintained for controlled drugs. Codes being used are being identified on MAR charts, as previously required and the acting manager confirmed that this has been reiterated to nursing staff. A requirement was made at the last inspection that all medications prescribed, particularly in relation to creams/ointment are signed for by the person who administered them. The acting manager confirmed that this has not been addressed as yet, but is aware of this requirement and will be taking action to address this shortfall with staff and other relevant professionals. This is not reflected as an outstanding requirement as it was confirmed that action will be taken. It is recommended as good practice, that any hand written prescriptions are checked and signed for by two staff who are trained in medication procedures, to ensure residents and staff are safeguarded from errors being made. It was confirmed that the registered nurses administer the medication to all residents. There are photographs on the MAR charts to assist staff in identifying
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 13 residents. Following a requirement made at the previous inspection, the acting manager confirmed that she monitors the MAR charts on a regular basis and any errors noted are addressed with the relevant nurse. It was noted that there were no warning signs in place for a resident who required oxygen. No requirement has been made in respect of this as the acting manager addressed this shortfall on the day of the site visit. A temporary sign was made and the acting manager was to going to contact the supplying company to supply the correct signage at the next delivery. Residents spoken with confirmed that staff respect their privacy and dignity. Staff were observed to knock on room doors before entering. Staff were observed to have a good professional rapport with residents. Signatures are obtained from residents to identify that they are happy to share a room. Barons Down DS0000013960.V338853.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): 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. 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. A staff member stated that they felt that more activities are being provided since the acting manager has been in post. It was confirmed that those residents who may require to remain in bed due to health needs are supported to go to the lounge room every couple of days for social interaction. The Inspector was informed that some of the activities provided by staff are dominoes, musical mornings and knitting etc. The AQAA identifies that it is recognised by the home that more social activities could be organised for residents, however many of the residents do not show interest in group activities. It was identified in what they could do better, is to have more one to one activity with care staff and a key worker system will be introduced to assist in this process.
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 15 Residents spoken to confirmed that their daily routines are generally their choice and are able to choose when to go to bed and when to rise etc. It should be noted that any minor shortfalls that individuals had with residing at the home were generally discussed with the acting manager on the day of the site visit or the individuals chose to address their issues with the home directly. Visitors are welcomed and encouraged to visit the home. There are no restrictions imposed for visitors. Of the residents that were asked, all confirmed that they are able to receive visitors in private. Visitors spoken with confirmed that they are welcomed at the home and can visit their friend/relative any time. The Statement of Purpose/Service Users Guide identifies that residents are supported to maintain their religious beliefs if they wish. It was confirmed that a representative from a church visits the home. There was an agency cook working at the home on the day of the site visit. Some residents commented that they felt the choice and standard of meals provided has decreased. It was confirmed by the acting manager that this is a temporary arrangement in the absence of the cook. Most residents were complimentary about the food being provided at the home. Most residents spoken with confirmed that there is generally a choice of meals available. Comments about the food ranged from ‘OK’ to ‘excellent’. The dining tables can only accommodate ten residents at meal times. Other residents were observed to be assisted in the lounge area and staff confirmed that other residents were eating in their rooms. Residents are able to choose where they eat. The Inspector ate fish and chips with seven residents at the dining table. Residents were observed to be enjoying their meal. It was observed that some residents might take a while to eat the food provided and staff were observed to go between residents to assist them. It was discussed with the acting manager that consideration be made to ensure meals remain warm for those residents who take a long time to eat their food, due to their independence being encouraged and supported. Plate guards were observed being used for some individuals to assist them in maintaining their independence. It was observed that two residents being assisted to eat were slumped in their chairs. The acting manager confirmed that these residents will often slide down the chairs of their own accord. The Inspector discussed with the acting manager that staff were observed not to assist the individuals to sit upright at the commencement of the meal. Another staff member was observed to be standing over a resident when assisting them to feed. No requirement has Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 16 been made is respect of this as the acting manager confirmed that she will address this with the staff. Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 17 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): 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 feel comfortable to raise concerns, however lack of records maintained does not evidence that these are dealt with appropriately. Training staff in Safeguarding Adult procedures will ensure themselves and residents are better safeguarded. EVIDENCE: There is a complaints procedure available at the home and a copy of this is provided with the Statement of Purpose/Service Users Guide. There has been one complaint made to the home since the last inspection. The complaint was regarding the offensive smell within an individual’s room. This complaint was substantiated and appropriate action was taken. It was recommended to the acting manager that a central log of complaints be maintained. The AQAA identifies that there have been seven complaints in the last twelve months, of which four were upheld. The records for these complaints were not identified to the Inspector at the site visit. Of the residents that were asked, most confirmed that they would feel comfortable to make a complaint and feel that appropriate action would be taken. The procedure for Safeguarding Adults was viewed. This needs to be amended to ensure that this provides clear guidance to staff that all allegations of abuse
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 18 must be referred to Social Services, who are the lead authority. It is not for the home to undertake any investigations without prior guidance from the leading authority. The acting manager confirmed that she and some staff have undertaken Safeguarding Adults training. A nurse spoken with confirmed that she has not had any Safeguarding Adults training, however demonstrated that she is aware of the basic procedures to take in the event of an allegation of abuse being made. This person is often in charge of shifts when the acting manager is not on duty. The acting manager must ensure that all staff, with priority given to those who may be in charge of the home, are provided with Safeguarding Adults training. It was confirmed by the acting manager that two residents observed to be sat in recliner chairs with the footrest out were being used for the individual’s safety and not as a form of restraint. Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 19 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): 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. Some individual rooms were seen to be personalised to reflect individual’s choice and character. Of the residents that were asked, all confirmed that they were happy with their individual rooms. There are suitable toilet and bathing facilities provided throughout the home to meet the needs of the residents. Two rooms have a shower in the en suite,
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 20 however people must be able to mobilise to use these facilities. These are showers that individuals must step into. The acting manager confirmed that the home has been assessed by an Occupational Therapist in October 2006. It was confirmed that recommendations were made and the acting manager has taken these on board on took appropriate action where necessary. The AQAA identifies that there are policies and procedures in place for the control of infection and six staff have undertaken infection control training. The home was free from offensive odours on the day of the site visit. The acting manager confirmed that there is a window and deep carpet cleaning programme in place to ensure all carpets are kept clean. Consideration should be made to replacing carpets in areas where they are wearing thin and looking dirty despite being deep cleaned. Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 21 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): 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 number and skill mix of staff on duty and are generally safeguarded by the recruitment procedures in place. EVIDENCE: Residents spoken with were complimentary about the staff working at the home and residents and staff confirmed that they felt there were sufficient numbers of staff on duty for the current number of residents. A couple of residents commented to the Inspector that there have been numerous changes over the past few years in management and staff and that they have not been provided with good continuity of care. It was confirmed that some areas of care have improved with all the changes within the home. It is identified in the Service Users Guide and confirmed by a staff member at the site visit that there is always a registered nurse on duty along with five care staff in the morning, three care staff in the afternoon and one care staff at night. All staff work a waking night duty. The rota provided to the Inspectors demonstrates that there are suitable numbers of staff on duty to meet the current needs of residents. Staff files viewed demonstrated that generally suitable recruitment procedures are followed. One staff member had commenced employment prior to a Protection of Vulnerable Adults (POVA) First check being obtained. A Criminal
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 22 Record Bureau (CRB) was returned within two weeks of this person commencing work. The acting manager confirmed that this person had been employed from overseas and they had received a copy of the police check from that individual’s country. No requirement has been made in respect of this, however it was reiterated to the acting manager that all staff must have at least a POVA First check in place prior to commencing employment and work supervised until an enhanced CRB is obtained. It was confirmed that Personal Identification Numbers (PIN) for registered nurses are viewed to ensure that they have current registration with the Nursing and Midwifery Council (NMC). It was discussed with the acting manager that confirmation of registration be obtained from the NMC who are the registering body for registered nurses. The acting manager confirmed that there are eight care staff employed at the home, of which two have obtained National Vocation Qualification (NVQ) level 3. One carer is currently undertaking NVQ level 2 training and four are doing NVQ level 3. On completion of these studies, the home will have over the recommended 50 of care staff qualified to NVQ level 2 or above. A staff member spoken with confirmed that she has received manual handling training, however no other training has been undertaken recently. Training records were not observed on this occasion as the acting manager confirmed that she is aware that staff are due for training updates. She confirmed that she has already raised this shortfall with the registered providers. No requirement has been made in respect of training as it was confirmed that action is being taken. This will be monitored during the inspection process to ensure compliance. The AQAA received identifies that further improving the training to staff is an area that they could do better. The acting manager confirmed that there is an induction programme in place, however the AQAA does not identify that there are policies and procedures in place for Common Induction Standards. The acting manager must ensure that the induction and foundation programme in place complies with the Common Induction Standards and meets the Skills for Care expectations. This has not been reflected as a requirement but will continue to be monitored for compliance throughout the inspection process. Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 23 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): 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. Implementing a quality assurance and quality monitoring system would enable management to monitor the success of the home in meeting 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. She has approximately seven years experience in a management position. An application has been requested to commence the registration process with CSCI to become the Registered Manager. The acting manager confirmed that she is looking into undertaking
Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 24 the Registered Manager Award course and is currently in discussion with the registered providers regarding doing this course. Staff spoken with confirmed that they find the acting manager supportive and approachable and is open to trying out new ideas staff may suggest. It remains an outstanding requirement that the home develops and implements a quality assurance and quality monitoring to ensure the home is run in the best interest of residents and meets the aims and objectives. The home has a compliments folder and written comments received from friends/relatives were ‘Thank you and your staff for their exceptional care and help with …’ and ‘… could not have been in a better place’. The acting manager confirmed that the home does not hold personal allowances for residents. Residents have their own measures in place for the handling of their money. The acting manager confirmed that she has implemented a programme to ensure that staff receive supervision at least six times a year. A staff member spoken with confirmed that they have received one supervision session to date. Providing supervision for staff has not been reflected as an outstanding requirement as action is being taken to address this shortfall. This will continue to be monitored for compliance throughout the inspection process. A fire risk assessment has been undertaken in February 2006 and the acting manager confirmed that she had not familiarised herself with this documentation yet. The recommendations made in the risk assessment have not been addressed. Priority must be given to ensure that people in charge of the home are aware of the fire risk assessment and ensure appropriate measures are in place to reduce these risks. The acting manager confirmed that fire lectures are undertaken every six months and fire drills are undertaken. It was confirmed that night staff have not participated in any fire drills. No other health and safety records were viewed. The AQAA identifies that equipment used are serviced or maintained as recommended by the manufacturer or other regulatory body and that there are written assessments on the Control of Substances Hazardous to Health (COSHH). Barons Down DS0000013960.V338853.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 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 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 2 X 1 X 3 3 X 2 Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 26 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 OP16 Regulation 17(2) Schedule 4(11) Requirement That a record is kept of all complaints made and includes details of investigation and any action taken to evidence that the home deals with these appropriately. That all staff receive training in Safeguarding Adults and policies and procedures in place reflect current guidelines. This is to ensure that service users are safeguarded and allegations of abuse are dealt with within the current guidelines. 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 to ensure that home is run in the best interest of service users and that the aims and objectives of the home are met. Timescales 01.04.06 and 19.09.06 not met. That all staff who are left in charge of the home are familiar with the homes fire risk assessment and action is taken to reduce these risks. This is to
DS0000013960.V338853.R01.S.doc Timescale for action 30/08/07 2. OP18 13(6) 30/08/07 3. OP33 24 30/08/07 4. OP38 23(4)(a) 30/08/07 Barons Down Version 5.2 Page 27 promote the safety of all people within the establishment. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations That any hand written prescriptions are checked and signed for by two staff who are trained in medication procedures, to ensure residents and staff are safeguarded from errors being made. Barons Down DS0000013960.V338853.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local 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 DS0000013960.V338853.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!
