Inspection on 06/07/06 for Manor Barn

This inspection was carried out on 6th July 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Barn 02/04/08

Manor Barn 19/06/07

Manor Barn 20/10/05

Manor Barn 19/05/05

Manor Barn 22/02/05

Manor Barn 23/08/04

Manor Barn 04/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Manor Barn Wattsfield Lane Kendal Cumbria LA9 5HF Lead Inspector Ray Mowat Unannounced Inspection 6th July 2006 08:15 Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 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 Manor Barn DS0000022687.V295602.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 Adults 18-65. 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. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Barn Address Wattsfield Lane Kendal Cumbria LA9 5HF 01539 735025 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) carol.pounder@oakleatrust.co.uk The Oaklea Trust Miss Shelley Louise Stokes Care Home 5 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (3), Physical disability over 65 of places years of age (4) Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 5 service users to include: up to 2 service users in the category of LD (Learning disabilities) up to 3 service users in the category of LD(E) (Learning disabilities over 65 years of age) up to 4 service users in the category of PD(E) (Physical disabilites over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 20th October 2005 2. Date of last inspection Brief Description of the Service: Manor Barn is a converted barn, in a residential area of Kendal, Cumbria within walking distance of the amenities of the town centre. It is registered to provide residential care for five people with a learning disability, some of whom may have elderly needs or a physical disability. The accommodation is on three floors. There is ramped access to the property from a car park at the front of the building. There is a small garden to the front and a larger private garden to the rear of the building, which leads to a riverside walk. On the lower ground floor there is a self-contained flat, this has a lounge with a small kitchen/dining area, a single bedroom with fully accessible en-suite toilet and shower facilities. Also situated on the ground floor but separated from the registered accommodation, are several rooms used as offices by the Trust. The middle floor has three single bedrooms, two of which have en-suite facilities and showers. There is a large lounge/dining room leading to a kitchen and utility room. The upper floor has a self-contained flat with a single bedroom, with ensuite facilities and a lounge with kitchenette. Also on this floor is a staff sleepin room, which is also used as an office. The fees for the home are currently £642.60, described as a basic unit price in the pre inspection questionnaire. Inspection reports are made available to residents and their representatives on request. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this key inspection I visited the home and met with all the residents, I also joined in an activity and had lunch with a small group of them. I met with the manager and two staff on duty. I received surveys from residents, other professionals and families/representatives, in addition to contacting other professionals involved with the home. What the service does well: What has improved since the last inspection? What they could do better: The home must make sure all risks have been identified to keep residents and staff safe at all times. The home must ensure there are enough members of staff on duty at all times. The flooring and decoration of the home must be kept in good order. It is recommended up to date information is held in care plans. The home should try to ensure there is a mix of male and female staff to meet personal care needs. The movement of staff at short notice is unsettling for residents and affects the running of the home. The home should keep records relating to checks on staff. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 6 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. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5. Quality in this outcome area is good. Detailed assessments are completed by the home in addition to the social work and specialist assessments. This provides staff with valuable information enabling them to provide a personalised and consistent level of service. This judgement has been made using all available evidence including a site visit. EVIDENCE: There have been two new residents admitted to the home since the last inspection, one of these being an emergency placement. In addition one of the existing residents has moved from the independent flat downstairs, up to the main body of the home on the first floor. This came about when the home had a vacancy on this floor and this resident needed a period of convalescence after an accident. This gave them the opportunity to “try out the home” with more staff support. After a period of consultation the resident chose to move upstairs. I talked to them about the move and they confirmed they were “happy with their choice”. A prospective new resident was referred to the home with a view to moving into the flat downstairs, again this was a planned process which gave the resident and the home an opportunity to make an informed choice. This again has been a positive move with the new resident settling in well. Planned moves of this nature that provide an opportunity to “test drive” the home is good practice. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 9 The second new resident came to the home as an emergency admission, however despite this the home worked closely with the other agencies to make it as smooth a transition as possible, with assessments and strategies put in place in a timely manner. This included developing a person centred plan to support the resident and staff through the move. The majority of referrals to the home are from a Social worker therefore all the residents have a Social work assessment on file. There was also evidence of specialist assessments and the home completing their own needs assessment, which are all used to compile the comprehensive care plans. In particular the home have some excellent communication assessments, which are valuable for ensuring the staff understand residents and communicate with them in a consistent manner. All the residents had an up to date contract of terms and conditions signed and agreed and held on file. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10. Quality in this outcome area is adequate. The home has good systems to record and monitor the needs of residents and works closely with other agencies to ensure needs are responded to appropriately. Care plans are improving with the introduction of a person centred approach. Risk assessments need developing for specific challenging behaviours to safeguard residents and staff. This judgement has been made using all available evidence including a site visit. EVIDENCE: As described previously the home has their own detailed assessment of needs in addition to other specialist assessments. From these assessments detailed care plans have been developed. These provide staff with information about the levels of support people require to lead an independent and fulfilling lifestyle. The home was in the process of introducing “person centred care plans”. It was evident residents had been totally involved in the process and two of the residents took great pride in showing me the progress they had made in developing them. For one person this involved putting together a ‘lifeline diagram’ using photographs and drawings to record their life history. This approach has had positive outcomes for the residents and is good practice. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 11 The home is working closely with a number of professionals to develop specific management plans for residents to help them manage difficult and challenging behaviours in a consistent manner. These have been kept under review and adjusted in response to changing needs. The home had developed some excellent communication plans for people that described how they prefer to communicate and the meaning of common words, gestures and symbols that the person uses. These are invaluable in giving staff a better understanding of people and encouraging a consistent approach that values the individuals rights and choices and how they make their needs known. A good example of this is the use of “Widgit symbols” to support the written text in documents for residents and with one resident in particular, the use of a daily planner, in Widgit format, to help structure their day which is important to them. One of the resident’s files contained some information and strategies that were no longer relevant that could cause confusion. It is recommended the content of this file be reviewed. On the whole the home has a good range of personal and general risk assessments, however they need to develop a risk assessment that encompasses challenging behaviour and how staff should respond to maintain their own and the residents safety at all times. Based on discussions with them staff are aware of the need to maintain confidentiality at all times. However the manager described how this had been an issue, with staff speaking about a resident to a colleague when a different resident was present, which she was now monitoring when working alongside staff. Information held on the computer system is securely stored with a password being required to access information. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. The home provides a wide range of activities to residents, who have a lot of autonomy in choosing how they live their lives. There was evidence of consultation and planning to ensure people’s choices are respected and responded to. This judgement has been made using all available evidence including a site visit. EVIDENCE: Four of the residents do not attend any formal day service although two of them do enjoy attending leisure courses at the local college. One resident attends a local day service on a full time basis, which provides them with both vocational, educational and leisure interests. They particularly enjoy a work experience placement for office skills, which has led to a part time job in a voluntary service. This is not only a positive experience for them but also a valued role in the local community. Residents are supported by staff from the home to pursue their interests and hobbies both in the home and in the community. There was a more structured approach to planning people’s days, however residents have the autonomy to change their plans. On the day of the inspection one resident chose to have a sleep in so the plans for the day were adjusted accordingly to accommodate Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 13 them. One resident was going to visit a relative in a nearby town so the trip was used to take another resident shopping, which was good use of resources and staff time. Based on discussions with residents and staff there was a good range of activities provided that were suitable for the individual residents. Sometimes people went in small groups to activities if they have similar interests, whilst other activities were on a one to one basis. I joined in with a resident in the morning who was participating in a sedentary activity with staff. The staff were skilled at maintaining their interest and getting maximum value from the activity. In the afternoon a craft activity took place which they obviously enjoyed and involved different skills. Again staff provided unobtrusive support taking on an enabling role and encouraging independence throughout the task. Throughout the inspection residents talked to me about a planned garden party for the coming weekend. The residents had obviously been involved in the planning and preparations for the event, they all knew their responsibilities on the day and were really looking forward to it, even discussing which outfit to wear. This level of involvement is good practice. After discussions at a resident’s meeting the home has recently acquired an allotment, which residents, with support from staff, were looking after. A music therapy session had also been booked and visits to the local swimming pool had taken place, which also proved popular. Consultation and planning in this way ensures people can make informed choices in their lives. I joined a group of residents for lunch, which was freshly prepared and well presented, in fact some mint grown on the allotment was used in the meal. The meals and mealtimes are very flexible and planned around the needs and preferences of the residents who have a lot of autonomy in the choosing and preparation of meals. Choices are confirmed using a pictorial menu book, which is good practice. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. Despite the issues raised regarding the level and deployment of staff in the home, I feel overall the personal and healthcare needs of residents are well documented and the majority of the time people receive an appropriate and responsive service. This judgement has been made using all available evidence including a site visit. EVIDENCE: Care plans and other relevant information document an individual’s personal and healthcare needs in detail, which provides staff with valuable information to guide and support them in providing a consistent level of service. Despite this level of information and with ongoing support from specialist health agencies, this was proving a challenge with one resident, who can exhibit particularly challenging behaviour. I feel the fact the home is funded and operated on a “shared care” basis is contributing to these pressures. The package of care required and the challenging demands of the individual at times are very difficult to meet because of the needs of the other residents. This can result in residents not receiving the care and support they need and puts staff in a very difficult and stressful situation. I realise a site visit to a home is a snapshot, however the staff on the day of the inspection provided a varied and fulfilling days activities to all the residents, both in the home and in the community. Staff showed good skills in communicating with and supporting and guiding residents so as to promote independence and choice, in Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 15 addition to meeting emotional needs. The home must review the deployment of staff and the numbers of staff, to ensure there is sufficient cover at key times to enable individual needs to be responded to. All the residents have access to a GP of their choosing and as described previously the home works closely with a range of other agencies and health professionals to ensure individual/specialist needs are responded to. The home uses health action plans, which record all health related information including a medical history, to monitor and record all health interventions. I examined the medication records (MAR charts) against the contents of the medication cabinet and found these to be up to date and in order. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. Policies, procedures and practice in the home were sound and ensure residents and staff are safeguarded at all times. This judgement has been made using all available evidence including a site visit. EVIDENCE: I examined the complaints and compliments record there have been no recorded complaints since the last inspection and there were two compliments. One was from the regional manager of the Trust and the other was from another agency that had been working with the home. They both reflected the “good joint team working and commitment of staff”. Staff spoken to were aware of their role and responsibilities in safeguarding residents and have received relevant training, in relation to mistreatment and abuse of vulnerable adults. Suitable policies and procedures were in place to guide staff practice. A handover checklist is completed at the end of each shift, which includes the checking of money tins and medication and any other pertinent information. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is adequate. On the whole the home is safe and comfortable and suitable for the needs of the residents. However some shortfalls were noted that must be addressed in relation to the décor and furnishings. This judgement has been made using all available evidence including a site visit. EVIDENCE: The home has compiled a three-year plan of maintenance and renewals that is included in the house development/business plan. This identifies work to be completed and the proposed timescale. The carpet in the lounge is worn and stained and was identified to be replaced in April 06, however this has not been completed although residents have chosen a suitable replacement. The home is required to replace this carpet as soon as practicable. The ceilings on the first floor are in need of repair due to plaster coming loose where clout nails have been used to secure the plasterboard. Remedial action must be taken to repair the ceilings. This is also subject to a requirement. The bathrooms and toilets are suitably adapted making them accessible to all the residents with relevant aids and adaptations in place. These include a bath hoist and fully accessible walk in shower. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 18 In addition to residents being involved with tending to the allotment, residents with staff support have planted up some flower tubs at the front of the home, which were attractive and the residents were involved in maintaining them. Resident’s rooms were personalised and reflected their individual tastes and lifestyles. One resident took great pride in showing me round his room and talking to me about his interests and hobbies. The home has appropriate policies and procedures in place to guide staff to maintain the cleanliness and hygiene of the home and control infection. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 33, 34, 35, 36. Quality in this outcome area is adequate. Although it is acknowledged that staff are very committed and are working hard to maintain a good quality of life for the residents, there is a need for the home to review the deployment of staff and the number of hours provided. In the evenings in particular the number of staff on duty can be problematical, which affects the quality and continuity of care for residents. This judgement has been made using all available evidence including a site visit. EVIDENCE: As discussed in a previous section of this report the home is required to review the deployment of staff and the number of staff hours allocated to the home. In particular the home should focus on the afternoon/evening shift when incidents have occurred and staff resources have been stretched. The redeployment of a member of staff at short notice with no planned replacement has been disruptive to the team and put the remaining staff under pressure at a difficult time. It is recommended the home review its procedures for such transfers and consider having a contingency plan. The on-call rota has been reviewed to ensure supervisory staff are additional to the homes allocation of staff, when they are covering the on-call. However it is evident from discussions with staff, supervisors are expected to cover the on-call rota on their weekend off. This does not appear to be appropriate or conducive to staff having a suitable break from their work and could result in a hidden cost to the home and be detrimental to staff and residents. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 20 It is recommended the manager review the gender mix within the staff team, as there is disproportionate number of female staff with three of the residents being male and one of the female residents being known to benefit from male staff input. It was evident from the records in the home that staff receive regular supervision from either their manager or immediate supervisor. The content of the supervision is suitable and has been invaluable in supporting staff through a challenging period for the home. Supervisions are recorded and actions agreed and signed by both parties. Regular team meetings are also held where staff can share concerns and discuss practice issues to maintain a continuity of care. Joint meetings have been held with the other agencies involved and a further three days of specific training is planned to support the staff team and enable them to reflect on their practice. All staff had completed their induction and foundation training in addition to receiving other specific training. Three care staff had completed their National Vocational Qualification (NVQ) and the manager and supervisor have completed the NVQ 4 and a management development programme. The home has robust recruitment procedures, however records are not all retained in the home as the personnel department hold them centrally including Criminal Record Bureau (CRB) disclosures. It is recommended the home maintain a record of the name, date of birth, CRB disclosure number and the date of issue for all staff disclosures. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42. Quality in this outcome area is good. The management team provide a good support network and make themselves available to staff. Residents are consulted formally and also more informally on an ongoing basis. It was evident their views are heard and actions taken accordingly. The records, policies and procedures of the home ensure the interests of residents and staff are safeguarded. This judgement has been made using all available evidence including a site visit. EVIDENCE: The manager and supervisor have both completed their NVQ 4 and management development programme, which has provided them with valuable knowledge and a chance to reflect on their practice. The manager has had a mentor, which has been beneficial to them and a good support. Staff spoken to feel support in the home is good, one described it as a “well run home” and said “communication is good and we know what we should be doing”. The manager said she had made a conscious effort to spend more time on shift with staff during the difficult periods. There was a high level of Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 22 commitment evident from the manager and supervisor to support staff even when they were off shift. Issues were also raised about the need for experienced staff to cover absences due to the complex and challenging needs of residents. This was raised with the manager who is addressing the issue. A formal Quality assurance consultation took place earlier in the year with the home using a questionnaire in an accessible format (Widgit). From the results of this a house development plan was produced, which was shared with residents and other interested parties. The agreed actions reflected resident’s rights and choices with issues such as choosing meals, the décor of the home and how to spend their day, being examples of the issues raised. I received very positive feedback from two relatives, one said they were “delighted with all aspects of care” and the other acknowledged the “effort and hard work of the staff in making the move into the home smooth and welcoming” Resident’s meetings are held on a regular basis where all aspects of home life can be discussed and actions agreed. All parts of the home were free from hazards. The home completes a monthly health and safety checklist to monitor the environment and maintain the safety and welfare of residents. The records required by regulation were examined and found to be up to date and accurate. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 3 3 X 3 3 X Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 24 Yes 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 YA9 Regulation 13 Requirement The home must develop risk assessments in relation to managing challenging behaviour to safeguard residents and staff. The home must review the deployment of staff and the numbers of staff, to ensure there is sufficient cover at key times to enable individual needs to be responded to. The home is required to replace the lounge carpet as soon as practicable. Remedial action must be taken to repair the damaged plaster on the ceilings. Timescale for action 01/09/06 2 YA33 18(1) 01/09/06 3 4 YA24 YA24 23 23 01/09/06 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended the content of the care plan file identified is reviewed to ensure up to date and relevant information is held. DS0000022687.V295602.R01.S.doc Version 5.2 Page 25 Manor Barn 2 YA31 3 4 YA33 YA34 It is recommended the home review the gender mix within the staff team, as there is disproportionate number of female staff with three of the residents being male and one of the female residents is known to benefit from male staff input. It is recommended the home review its procedures for redeploying staff at short notice and develop a contingency plan for such events. It is recommended the home maintain a record of the name, DOB, disclosure no and date of issue of the CRB disclosure for all staff in line with good practice guidelines. Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Manor Barn DS0000022687.V295602.R01.S.doc Version 5.2 Page 27 - 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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