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Inspection on 23/04/07 for Barton Grange

Also see our care home review for Barton Grange for more information

This inspection was carried out on 23rd April 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a particularly warm and relaxed atmosphere. The staff ensure the well-being and comfort of the residents` and treat them with great respect and kindness. For example 10 residents spoken with said, "the home is lovely, the staff are kind and caring, and the food is good." Meals are varied, well balanced and nicely presented offering choice and variety. All meals are home cooked with plenty of fresh ingredients, fruit and vegetables. Staff communicate well with each other and with external professionals, to ensure that each resident receives the best possible care.

What has improved since the last inspection?

The bathrooms are now all useable with equipment to assist residents with bathing as needed. They are well decorated and hot water outlets thermostatically controlled. Radiators in all bedrooms and corridors are now guarded to safeguarded residents from potential harm. Staff recruitment practices have been tightened to ensure all required records are kept in the home.

What the care home could do better:

Contracts of residency are not very clear about the amount of fees to be paid and by whom. This information should be included so that residents and relatives can clearly see how the fees are to be paid and who is contributing what amount. The environment is homely and comfortable but tired and shabby in some areas and needs redecorating. Staffing levels need to be maintained at the planned level to ensure residents care needs can be met effectively. Mandatory staff training needs to be provided and accessed by all staff to ensure they have update knowledge and skills to provide best practice care to residents. While residents views are asked they are not currently collated into a formal report. This would be better practice and show how resident views are taken into account in the running of the home. Fire doors need attention to ensure good closure to protect residents from potential harm. Other safety issues identified to be addressed for the provision of a safe environment.

CARE HOMES FOR OLDER PEOPLE Barton Grange Barton Road Barton Winscombe North Somerset BS25 1DP Lead Inspector Patricia Hellier Unannounced Inspection 10:00 23rd April 2007 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 Barton Grange DS0000049161.V327366.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. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barton Grange Address Barton Road Barton Winscombe North Somerset BS25 1DP 01934 842827 NONE 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) Scosa Ltd Ms Sarah Jane Matthews Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 8th June 2006 Brief Description of the Service: Barton Grange provides personal care for up to 20 elderly residents. The home is situated on the outskirts of the village of Winscombe. Mr and Mrs Scott, trading as Scosa Ltd bought the home in June 2003. Ms Sarah Matthews is the registered home manager. Accommodation is in a Victorian country house with a modern extension. Seven of the bedrooms are on the ground floor. There is level access to these rooms. The remaining bedrooms are on the first floor. A stair lift is provided on both staircases. Additional steps to some of the rooms mean that residents with impaired mobility may not be able to access these areas. The rooms affected are clearly identified in the service user guide. None of the bedrooms have en suite facilities. There is a large garden with lawns at the front of the building and a patio area to the rear. The home can sometimes accommodate residents’ pets, subject to prior agreement. The fess range from £365 - £450 per week with additional charges being made for hairdressing, chiropody, newspapers, and toiletries. This information was provided in April 2007. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over 7.5 hours and two days with the manager present throughout. Before the inspection the information about the home was received from the file held in the office, a review of the last inspection report and all correspondence since the last inspection. It was not possible to send comment cards to residents, relatives and Health Care Professionals that visit the home, as the information was not available to CSCI prior to the inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 10 residents, 2 relatives, one Health Care Professional and 4 staff, observation of practices, tour of the premises, review of documents relating to care, recruitment, health and safety; review of policies; inspection of medication records and storage. The relatives spoken with said of the home “it’s really nice, my relative is well cared for”; “the staff are very kind and caring”. All residents and staff spoken with told the inspector that the home was good and the staff very kind. Comments received were “it is very homely and comfortable”; “my care needs are well met”. What the service does well: What has improved since the last inspection? The bathrooms are now all useable with equipment to assist residents with bathing as needed. They are well decorated and hot water outlets thermostatically controlled. Radiators in all bedrooms and corridors are now guarded to safeguarded residents from potential harm. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 6 Staff recruitment practices have been tightened to ensure all required records are kept in the home. 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. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,2,3,4,5 The Brochure and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: Residents are provided with a comprehensive Service User Guide containing the required information to ensure they or their relatives are able to make an informed choice of residence. The Statement of Purpose is available in the hall area of the home together with past inspection reports, providing clear information to all visitors to the home. Some of the information in these documents is out of date and should be revised to reflect the true picture of the home. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 9 All residents were aware they had a contract of residency and were happy with the provision that they receive. On inspecting the Terms and Conditions of residency document the weekly fees to be charged are clear, but it does not show who contributes what amount to make up the weekly fees. This should be included for clarity for residents and their relatives and in line with the recommendations of the recent “Fair Price for Care report”. Care needs are well met through a full assessment process and the completion of a care plan from this information. The assessment includes all the elements listed in the standard. A comprehensive assessment was seen for a recently admitted resident. The resident when spoken to said ‘I am well looked after; they know what I need. I am getting used to it and the staff are interested in me, and helping me a lot.’’ Social services care plans had been obtained where relevant. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 7,8,9,10,11 Residents benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Personal and environmental risks are well managed. Medication practices are safe. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include a social history. Three care plans were inspected and all reflected clearly current identified health and social care needs. Evidence was seen of regular visits by the chiropodist and optician and residents being taken to other appointments as needed. Residents’ comments supported this. Clear actions to meet identified needs were recorded and regular evaluation noted. However reviews of care plans have not taken place in the last two months due to staff shortages. Care plans did not show resident or relative involvement and residents spoken with were unaware of these documents. It Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 11 is recommended that this be introduced to demonstrate the person centred approach to care that the home offers. Residents said that staff promptly reported to seniors if they have any problems that require attention, and that staff who come on duty later are always up-to-date with their needs. All care plans contained well-formulated risk assessments for falls and any environmental risks e.g. use of the stair lift. Other personal and environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. Daily records are not made but entries seen were respectful and contained relevant information to care needs and provision. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. Medication storage, receipt and disposal are well managed and an audit trail of medicines entering and leaving the home provides safeguards for residents. Medication administration records were appropriately completed. Due to staff shortages medication for two residents had not been re-ordered at the right time and doses were being missed while staff waited for the chemist to replenish the supply. Medication practice observed was satisfactory and in line with policy and good practice guidelines. Hand transcribed prescriptions were seen and these had not been signed by two members of staff when written, thus not providing the recommended safeguard for residents. The home does not have a policy for the administration of homely remedies. The manager understood the need for this and is planning to access the North Somerset PCT policy and discuss and agree it with the local GP’s. All residents spoken with felt that kind and caring staff respected their dignity and privacy. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Staff from overseas are employed at the home and feel well integrated to the team and life of the home. Staff and residents felt that they give breadth and interest to life at the home. Staff said, “we are all one happy family here”. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. The manager and staff are keen to ensure their good standard of practice in the final days of a resident’s life. One member of staff is a link person for End of Life care and is currently developing care plans for all residents for this stage of their life. This work is to be commended. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from very flexible routines and menus. The variety and number of activities offered provide daily variation and interest for people living in the home. . Residents right to choice and control over their lives is well respected, and encouraged. Friendly staff always welcomes relatives and visitors EVIDENCE: Many residents were able to tell the inspector the name of their key worker and the sort of tasks their key worker does for them. They described very warm relationships with the staff. A range of activities is provided with posters displaying information of forthcoming events in the front hall. Two residents said, “there is not a lot to do here, they could provide more activities, they tailed off of late”. Another resident told the inspector “they have been short staffed in recent weeks so less things to do”. Many residents spoke of outings with the staff and how much they had enjoyed the Easter outing. Two other residents spoke of how the staff take them out for lunch and coffee, or visits to the village when they Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 13 are able. Two other residents felt that one of the activities offered was rather childish and would like something different. The manager plans to discuss this with the company that provide the activity. During the inspection a member of staff was seen engaging a number of residents in a word game. The atmosphere was lively and all appeared to be enjoying themselves. All residents enjoy meeting in the lounge and said they have “many stimulating and enjoyable conversations”. Residents told the inspector they can see their visitors at any time and that routines are flexible. Residents said that they are given help promptly, and that staff always come quickly if they ring their call bells. Three residents said that in the last week or so this had not been the case as the home had been short staffed. Relatives were seen popping in during the course of the inspection and being welcomed by staff. One relative said, “I feel quite happy coming here and the staff are very good to me”. Comments made by relatives indicated that they were made welcome; “there is always a warm welcome when I visit”. A friendly banter was evident between staff and residents throughout the inspection. The dining room is homely and tables well presented. All residents said they liked the meals and felt that they provided a good balanced diet. The menus show a varied and interesting balance. The cook talks to each person about their meal preferences and any menu ideas. She regularly sees the residents to get more feedback. All meal are home-made from fresh ingredients. In addition to the usual cups of tea and coffee, a choice of cold drinks was regularly offered throughout the day. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16,17,18 Residents are confident that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. EVIDENCE: The home has a comprehensive complaints procedure and all residents have a copy of it. There have been no complaints since the last inspection. Residents stated that if they were not happy about anything they would speak to the manager. Residents spoke of Residents’ / Relatives’ Meetings where a variety of issues relating to the home are discussed. Minutes of these were seen indicating that all residents/relatives can have their say. Staff and residents spoken to, say the manager is very approachable and understanding. One resident said ‘I’ve nothing to complain about, it’s just like home – we are one family”. A system for keeping clear records of complaints received with actions taken and outcomes are available should any complaints be received. The home has a copy of the North Somerset ‘No Secrets’ Guide. A procedure for responding to allegations of abuse is available and staff were fully aware of it. All residents said, “The staff are very kind and take time”. “I can’t fault them”. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 19,22,23,24,25,26 Residents are provided with homely and comfortable surroundings. Health and safety issues are not well managed. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Robust Infection control practices are followed. EVIDENCE: Many parts of the home are really welcoming and comfortable with homely communal spaces. Residents’ rooms are personalised and comfortable. The lounge is furnished with a variety of suitable and comfortable chairs to suit residents’ needs. Some of the residents’ rooms have been newly decorated; others are looking old and shabby. Some areas, such as corridors and stairwells, are looking Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 16 tired and will need redecoration in the near future. A number of issues relating to the health and safety of the environment were noticed such as flaking paint and ill-fitting skirting boards and floor covering in toilets; a trip hazard from the ramp into the downstairs bathroom. A number of fire doors are not self-closing and do not fit flush to the doorframe to provide the necessary seal for the safety of residents. Although hot water outlets to baths are thermostatically controlled there was no thermometer for checking the temperature of bath water to prevent potential scalding. Radiators throughout the home have now been covered to provide protection for residents from potential harm. A development plan for the premises has been drawn up and the manager told the inspector that the provider is currently looking at the work needed to provide a safer environment. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 27,29,30 The home’s staffing levels are not always sufficient to manage the care needs of residents. The procedures for the recruitment of staff are robust and provide safeguards to protect residents. Staff training has been limited due to poor staffing levels. EVIDENCE: The staff rota for four weeks ahead was posted on the office wall. Three care staff should be on duty in the mornings, but in recent weeks there have been only two. Staff interviewed told the inspector that this is not sufficient and the manager does a lot of ‘hands on’ care work as well as managing the home. Staff said they felt staff levels were low due to lack of staff recruitment and staff sickness. The manager told the inspector that they have been seeking to recruit staff recently, but with little success. There are two staff on duty in the afternoons, supplemented by a junior who does some household chores for two hours in the early evening. The manager is on duty most weekdays, and sometimes works out of normal office hours. Either the manager or a member of senior staff is on call at weekends. At nights, one waking member of night staff and one person sleeping in covers the home. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 18 Residents reported “staff never rush us through personal care tasks but always go at our pace”. “Staff regularly make time for a chat”. Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, “how nice the staff are”, and many people gave examples of particular instances of kindness. Staff interviewed said, “the home is a happy place to work, we are like one big family”. Recruitment practices for the new staff employed since the last inspection were observed to be satisfactory and compliant with the required safeguards. New staff receive a home specific induction with key Health and Safety information and guidance about the homes routines and ethos of care. It is hoped that staff should undertake the Common Induction Standards programme however, at present, this is not possible due to staff shortages. Staff are keen to undertake NVQ training and it is hoped that this will be arranged for later this year depending on staffing levels and financial considerations. Training since the last inspection has been limited due to staffing levels. Staff have undertaken training in Moving and Handling, Safe Handling of Medicines, Fire Prevention and Safeguarding Adults. They have not received training in Health and Safety, First Aid or Basic Food Hygiene practices in the last year. This does not comply with the regulatory requirements of mandatory training to ensure the safety of residents. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 31,32,33,35,36,38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. Quality assurance processes in the home are not formal demonstrating that the home consults with residents, families and visiting professionals. Residents’ views are sought and acted on, but a formalised system is not in place. The management of resident’s monies are handled safely by the home Health and safety issues are not regularly monitored in the home and a safe environment not always maintained. EVIDENCE: Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 20 The manager gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available and seeks to ensure all their needs are met. One resident said she ‘can’t do enough’, ‘she is always helping”. Staff interviewed stated that they felt well supported by an approachable manager. The manger told the inspector that she is currently having talks with the provider as to the best way to address the environmental issues (mentioned above) in the home. Policies and practice guidance are provided in the home. However they are not dated and signed for accountability purposes and do not appear to have been reviewed. It is recommended that all polices are reviewed, signed and dated to ensure best practice policy and guidance is provided. The home does not have a formal quality assurance system. Samples of resident satisfaction surveys were seen, however there was no evidence to indicate how their suggestions were to be incorporated into an improvement plan thus providing an effective framework to ensure that monitoring and reviewing of the various aspects of quality assurance are undertaken and acted upon. A formal quality assurance system that complies with the homes policy is required for the facilitating of resident say to the running of the home. Residents’ pocket monies held by the home were inspected and found to be accurate and to have clear records. It is recommended that two signatures for any transactions are made for the safeguarding of all concerned. Supervision for staff is provided both formally, and informally at hand over times and other times, when the staff discuss resident’s care needs and how best to meet them. Records seen were sporadic and did not evidence the practices spoken of by staff and the manager. Records seen showed evidence that care practices for residents and training needs were discussed. Supervision records need to show that supervision is provided at least six times a year. Records inspected indicated regular safety and fire checks are carried out. Certificates of safety checks, servicing of equipment and other required safety inspections were seen. Staff spoken to confirmed that regular fire instruction and drills had taken place. Some fire doors were seen to be ill fitting and others wedged open thus not providing the safeguards required. The manager told the inspector that advice has been sought from the Fire Safety Officer in relation to the safety of the home, and the updating of the Fire Risk Assessment for the home and for any wedged open fire doors for the protection of residents. The manager was not aware of the timescales for the implementation of any recommendations from the Fire Safety Officer. Hot water outlets throughout the home are thermostatically controlled to reduce risk of burns and scalds. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 21 Currently the deputy manager is the only one who holds a valid First Aid certificate, thus a qualified first aider is not present at all times in the home. Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 22 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 2 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 3 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 3 18 3 1 X 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 X 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 1 Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23.4 Requirement To provide adequate arrangements for the containing of fire should it break out in the home To ensure that all parts of the home are reasonably decorated and in good repair – especially the toilets to prevent the spread of infection. Provide adequate staff at all times to meet the health and welfare needs of residents. To ensure that all staff receive appropriate training for the work they are to perform. This should including mandatory training. To develop an implement a full formalised quality assurance process that shows how the results are feedback to residents and their families, and the information used to inform the development of the home. Ensure that all parts of the home that residents have access to, are as far as possible free from hazards to their safety. Timescale for action 26/05/07 2. OP19 23.2 (d) 31/07/07 3 4 OP27 OP30 18.1 (a) 18.1(c) 31/07/07 31/07/07 5 OP33 24 31/07/07 6 OP38 13.4(a) 31/05/07 Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 24 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 Refer to Standard OP1 OP2 Good Practice Recommendations Review and update the Statement of Purpose and Service User Guide to ensure information is a current reflection of the home. To amend the Terms and Conditions of residency document to show the way in which the fees are made up and who is contributing what amount. That all hand transcribed medication records are signed by two members of staff to safeguard residents. The development and implementation of a Homely Remedies policy. To ensure supervision records are maintained for all supervision sessions; showing supervision to have taken place at least 6 times a year. 3 4 5 OP9 OP9 OP36 Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Barton Grange DS0000049161.V327366.R01.S.doc Version 5.2 Page 26 - 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. 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