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Inspection on 17/06/05 for St Barnabas Residential Home

Also see our care home review for St Barnabas Residential Home for more information

This inspection was carried out on 17th June 2005.

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

Residents throughout the inspection said that they felt the home provided a good level of care, within a "homely environment". They liked the staff, felt free to do what they wanted, meals were "good", and they could find "nothing to grumble about". A relative wrote that staff undertake their work with `a light touch and good humour`. Relatives of a resident who had recently passed away, praised the level of care and support given to the resident, and themselves, during this sad time. Residents spoken with enjoyed the "beautiful views" from their bedrooms, and gardens. Some enjoyed going for walks across the Common, or visiting the local Southwold shops.

What has improved since the last inspection?

Staff said they were receiving regular supervision, and the home has continued to invest in training staff. The home is starting to introduce new care plans for residents, which will be looked at in more detail during the next inspection.

What the care home could do better:

When a new resident applies to move into the home, staff are not always carrying out their own assessment. The home must take into account information given by families, Health and Social professionals. However they do need to undertake their own assessment. This is because the management know who they are registered to care for, have knowledge of staff skills, other resident`s needs, and the home`s layout. This all needs to be taken into account when deciding if they are able to meet the person`s care and social needs, before offering a place. The home must ensure that they keep their care records up to date, and staff write a true account of what has happened. To do this, the information should be written by the person who has seen an incident or provided the care. When employing staff, the home has not always undertaken pre-employment checks, to confirm who the person is, before allowing them to start work. Staff must check a person`s character and work history, to ensure that they are fit and safe to work at the home.

CARE HOMES FOR OLDER PEOPLE St Barnabas Residential Home The Common Southwold Suffolk IP18 6AJ Lead Inspector Jill Clarke Announced 17 June 2005 th 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 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. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Barnabas Residential Home Address The Common, Southwold, Suffolk, IP18 6AJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01502 722264 01502 726045 st-barnabas@tiscali.co.uk The Trustees Mrs Christine Reeves CRH 13 Category(ies) of Older people aged over 65 years and over, not registration, with number falling within any other category - 13 places of places St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28 February 2005 Brief Description of the Service: St. Barnabas set in a residential area of Southwold, is a short walk from the Town centre (and its range of amenities) and beaches. Public transport includes a bus service from Southwold, which connects with the railway station at Halesworth. The large house, built on the site of an old windmill has 3 floors, which residents can access by lift or stairs. All 13 bedrooms have their own wash hand basin, 3 also have ensuite toilets. Communal toilets and bathrooms are situated close to bedrooms, which are located on all 3 floors. Communal areas consist of a dining room, lounge (drawing room) and enclosed porch area at the front of the home. There is enclosed court yard, and gardens which face out to the Common and sea front. There is off road car parking at the side of the home, with further public car parking available a short walk away. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine inspection took place over 8 hours, during a weekday in June. Before the inspection, CSCI comment cards were sent out to the home, for residents, relatives and visitors. This gave the chance for people (who did not have to give their name) to give their views on the level of service provided and make any comments. Six residents, eight relative/visitors and three letters were sent to the Commission. Information gained from the letters and comment cards have been included into this report. During a tour of the building, all the residents living in the home were introduced, communal rooms and a sample of three bedrooms were looked at. Time was spent in private with three residents, to hear their views, on what it was like living at St. Barnabas. General feedback was also given during conversations with residents throughout the inspection. Time was also spent with two relatives and members of staff, which included the Chairman of the Trustees, Manager, Deputy Manager, Chef, and two care workers. Records viewed included, care plans, staff records and incident reports. Discussions during the day with people living at the home, and staff, dentified that they preferred to be known as residents, rather than service users. This report respects their wishes. What the service does well: Residents throughout the inspection said that they felt the home provided a good level of care, within a “homely environment”. They liked the staff, felt free to do what they wanted, meals were “good”, and they could find “nothing to grumble about”. A relative wrote that staff undertake their work with ‘a light touch and good humour’. Relatives of a resident who had recently passed away, praised the level of care and support given to the resident, and themselves, during this sad time. Residents spoken with enjoyed the “beautiful views” from their bedrooms, and gardens. Some enjoyed going for walks across the Common, or visiting the local Southwold shops. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 5. the home does provide intermediate care, therefore this standard was not applicable. Assessment of new residents is sometimes reliant on information supplied by their relatives. Where a qualified person does not undertake assessments, there is a potential risk of the home not being able to meet residents care needs. People using the service can expect to be given a residents ‘information pack’ on the home. To be more informative, the contents need to be checked, to ensure it is up to date, useful, and easy to read. EVIDENCE: Residents, who had completed the CSCI comment card, had written that they ‘liked living at the home and felt well cared for’. This was also reflected during time spent with residents, who felt that they would not “want to live anywhere else”. On admission, residents are given a contract which outlines the terms and conditions of their stay. Information given on who the home was registered with, and that the ‘Fire officer visits regularly’, was wrong. The contract did St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 9 not give clear information if relatives or their representatives, would be charged for the room following a resident’s death. The information given to new residents was seen. Some of the information was out of date. It gave limited information on what’s happening in the home, and the local community. The information comes in a pack, which consisted of several sheets of paper. The pack contents were not listed or put in a set order, to support residents in going straight to the information they may be looking for. Three care plans were looked at. One showed that staff had asked the relatives to complete the pre-assessment. No assessment had been undertaken by the home prior to admission. It was good to see relatives involved with the admission process and should be encouraged. The reason why the home has to undertake their own assessments was discussed. Reasons given was, that it was the management’s responsibility to sure they have the staffing level, environment and skills to provide the level of care required. One resident confirmed that they had visited the home, and their bedroom before moving in. They felt that the staff gave them the level of support they needed, and would be happy to spend the “rest of their days” there. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10. People living at the home can expect to receive a good level of care by staff that will respect their privacy and rights. However care records do not always reflect the level of care and support given. EVIDENCE: Residents spoken to felt that the level of care was “good”, praising the “caring” staff saying they “had nothing to grumble about”. One relative felt the level of improvement in their mother’s health since they were admitted, was due to the good standard of care, they received. Care records (care plans) looked at, gave information on what support residents needed with their personal care and mobility. Dates of care plan reviews, showed that the information in the care plan had not been reviewed monthly. Care plans held daily observations written by staff. However one care plan did not reflect the actual situation and care given. The records stated that the resident had ‘fallen’. Further discussions with staff identified that the resident had not, in fact fallen. The information in the records was written on behalf of another carer, who themselves had not witnessed the incident. This led to the St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 11 information written in the care records not giving an accurate account of what had happened. Records are written up once a day. Staff did not always state the time they had been written up, which would be more informative, when monitoring people’s physical and mental health. Another entry, recorded that the resident’s legs were ‘very swollen and red’. There was no follow up to say what action staff, if any had been taken by staff. A new care plan format is currently being introduced. The Management felt this would be a good time to talk to staff about care planning and recording of information. Staff spent time discussing residents care, showing that they had formed good working relations with the community Nurses and local Doctors Surgery. Discussions with residents identified that they had consulted a doctor over their health. A relative felt that staff ‘follow up all medical needs’ of the residents. Staff referred to one resident as having dementia. This was fed back to the manager who said the resident showed signs, but had not been formally diagnosed as having dementia. This led to discussions about having the resident assessed. If diagnosed, and the home was able to meet the person’s mental health needs, they could apply to have a place for Dementia, for the resident concerned. Residents felt that staff always respected their privacy, and called them by their preferred name. This was observed during the environmental tour, when staff introduced residents. Staff knocked on residents bedroom doors, and waited for permission, before entering. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. People using this service can expect to be supported to remain in control of their lives, be treated with kindness, respect and enjoy home cooked meals. EVIDENCE: One resident said that although “not drags”. Residents spoken to in their music systems. They said the home delivered. One resident was looking their afternoon viewing. a very sociable person - time never bedrooms had their own television and arranged for their daily newspaper to be up the television programmes, to organise The position of the home, gives residents uninterrupted views across the Common to Walberswick, Blythburgh, Southwold harbour and the sea. Residents, who have bedrooms looking out over the Common, said it got very busy at times with tourists; it was like having their own television set. Seating areas outside the front of the home, allows residents to sit out and “enjoy a cup of tea”. At weekends, staff said passers-by, sometimes mistakenly thought the home was a “Tea shop”, especially when residents have invited them to join them. A resident said they “loved wandering around the garden”, another said they enjoyed “going for walks – if it is nice”. Residents and relatives confirmed that visiting was flexible to individual residents wishes. The Manager said that St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 13 residents could meet their visitors in private, either in their bedroom or use the upstairs sitting room. The local shops and amenities of Southwold are a few minutes walk. Staff said they take residents in a wheelchair if they are unable to manage the walk. A relative who had been sent a copy of the August 2004 residents meeting, was ‘astonished to read the amount and variety of activities suggested by the residents’. The suggestions included visits to the theatre, cinema and meal at Dunwich. However the relative had not received any feedback if these activities had taken place. The information supplied to the CSCI by the home, did not confirm that these activities had taken place. Completed residents comment cards, showed that two residents felt the home did provide suitable activities. One felt they didn’t, and the remaining three had said only ‘sometimes’. The staffing level in the afternoon of two carers and the Manager restricts what external activities can take place. For safety, two carers would always be required at the home to give minimum cover. Staff said they try and arrange any outings in the morning, when there is an extra member of staff on. The manager said they would bring in extra staff if required, to support any special outings/appointments. One resident said “we get out when we can”. A small activity Therapy session was going on in the upstairs sitting room. Residents were looking at old newspapers and discussing historic events. With the inspection going on, the Activity person steered the conversations to inspections, and dealing with inspections and regulators during their careers. Which led to a lively discussion about schools, on what it felt like being inspected and the work involved. Four residents had stated on their comment cards that they liked the food, two had said only sometimes. Residents spoken with during the inspection enjoyed their meals. One resident explained that breakfast is brought up to their room, and that they go down for lunch and supper. Sample menus sent to the CSCI, showed one main meal on offer. Time spent with the Chef, identified that a second alternative was always offered, if residents do not like the main choice. The Chef said that they knew individual residents dislikes, and would talk to them, and arrange an alternate main course. The Chef also grows herbs and some of the vegetables themselves. The weekly lunchtime menu included, Lamb Cobbler, Roast Chicken, Plaice in Prawn sauce, all served with two vegetables and potatoes. Supper menu choices included, Home-made Soup, and Smoked Haddock. Desserts were offered at both lunch and suppertime. Residents said they are offered plenty of drinks. Sundays they are invited to have “a glass of Sherry before lunch”. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 People living at the home can expect staff to listen to any concerns they have, and take appropriate action to address them. EVIDENCE: Residents said that staff “listen to them”, and they had “nothing to grumble about”. If they did need to raise concerns they felt comfortable to talk to the staff or management directly. The home’s complaint procedure was located in hallway on a shelve, next to the home’s suggestion book. However only two out of the seven relatives/visitors comment cards, indicated that they were aware of the home’s complaint policy. The complaints policy gave timescales, and names of people who could be contacted. This included the Regional Director of the CSCI, as well as the local CSCI office. A suggestion was made to just give just the CSCI office details, to stop any delays whilst the complaint is redirected from the regional office. The complaint procedure did not make clear to the reader – that they could contact the CSCI at any stage of the complaint investigation. The Home’s Statement of Purpose, informs the reader where they can find the complaints procedure in the home. The Statement of Purpose should include all information, so it can be read by people both living in, and outside the home. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, 23, 24, 25 and 26. People living at the home can expect, a clean, homely, safe, environment, which should meet their needs. EVIDENCE: Resident’s comments on the environment included “comfortable lovely place”, “beautiful view from their window” and I have “got all I want”. One relative had raised their concerns over the small dining room, and need of an extra toilet downstairs. They had been led to believe that work was going to be undertaken, but had heard nothing. This was fed back to the management who said planning permission had been granted, but the committee still had to raise £125,000 for the project. An appeal has been started, and they had already received a donation of £32,000. The plans include an extension to the dining room, disabled toilet, and refurbished kitchen and laundry. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 16 An invite was received by one resident to view their bedroom, which they had personalised. Time was spent with two other residents in their bedrooms, which were all different in layout and size. They were all pleased with their room, which they had personalised with their photographs and possessions. The environment of the home was described as “comfortable”, residents said that their rooms had “all they wanted”. When a resident was asked if staff kept the home clean, they replied, “certainly do dear”. This was further reflected in written comments stating that the home had a ‘high standard of cleanliness’. Whilst being introduced to residents, who were in their bedroom, or sitting in the lounges, all areas of the home were clean, and furnished comfortably. One resident said that they had changed their bedroom since they moved in – because they preferred the view from the room they were in now. Residents were seen to move freely around the home, one resident said that they could use the lift on their own. Time spent with staff, confirmed that they had sufficient mobility aids to support residents with their transfers. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 People using the service can expect to be looked after by well-trained staff, who are committed to giving a good level of care. However the home is not always following safe recruitment procedures. This could potentially put residents at risk. EVIDENCE: When residents were asked during the visit if they felt there was enough staff on duty, they replied, “Yes, I think so”, “feels enough staff on duty” and “Yes – definitely”. Time spent with residents identified that although they felt there was enough staff, they had got used to going out in the morning, as there was less staff on in the afternoon. Residents felt staff had the skills and knowledge to care for them. The ‘trustees’ of the home are committed to ensuring that staff is fully trained. The pre-inspection questionnaire showed that eleven out of the fifteen staff had gained their NVQ 2 or 3. One member of staff said they had nearly completed their NVQ 3, and that they had found the training very useful. They felt the course not only gave their extra knowledge on caring for the residents, but also made them look at their own practice, and feel confident in their work. Other training staff has received over the last twelve months included, Continence Advice and Alzheimer/dementia awareness. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 18 A sample of two staff records, who had been employed in the last year were looked at. Both files had no recent photograph, or paperwork to validate who they were. One had commenced work on the CRB obtained by their last employer, which was before this practice was stopped (26/7/04) last year. The home had then applied and received a new CRB clearance, which included POVA checks. The second file raised concerns that the home had not submitted a CRB application, until three months after they had started work. The home’s employment application form, only requested the last 10 years of employment, instead of full employment history. The management was not aware of the changes in CRB, or amendments made to the regulations following this. It was felt that the commission should have informed the people running the home. This led to a discussion about the importance of the management keeping their own knowledge updated, in changes affecting the home. Which included reading newsletters, and looking at the CSCI website. A copy of the Department of Health’s Guide for Care Homes was shown, and information given how they could get their own copy. The home was asked to take immediate action, to ensure the safety of residents, that they obtain all the required recruitment paperwork, before they start staff working at the home. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38. 32,33,37 and People using the service can expect an approachable staff team, who are committed to running the home, in the best interests of the residents. Staff are not always completing or updating records accurately, which could potentially put residents and staff at risk. EVIDENCE: Before the inspection, letters and CSCI comment cards sent to the commission, contained people’s concerns over the retirement of the current Registered Manager, Mrs Reeves. They were concerned over the trustee’s handling of the situation. They felt Mrs Reeves had been treated unfairly and would be ‘greatly missed’. A resident had written that they felt the home ‘was exceptionally well run’. One relative had written that Mrs Reeves was ‘open, approachable and so kind’. Residents also expressed their concerns during the inspection. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 20 Although residents and staff were upset at the change, they gave their support to the new Manager Mrs Wendy Clack, who had been promoted from Deputy Manager. All residents and staff spoken with felt that it was a sensitive situation. They felt both the way Mrs Reeves and the new Manager acted during the changeover had been professional. Both had been supportive to residents, staff and each other. This was also observed throughout the day, as both Mrs Reeve and Mrs Clack, took an active role during the inspection. Whilst looking at a residents care records, an entry read ‘hurt my back when we were trying to get out’ of the lift. No incident report had been written, or investigation undertaken, to identify what had happened, and remove the risk. Time spent with staff confirmed that they had received manual handling training. The Pre-inspection questionnaire showed that all staff had been given training in Fire awareness and First Aid. Two Domestic staff had received training in the ‘prevention of cross infection’. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x 3 3 x x x 2 2 St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 22 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 3 Regulation 14 Requirement Pre-admission assessments must be undertaken by people who have the experience and training to be able to make a decision if the Home can meet all the prospective residents care and social needs. The home must ensure that information in care plans is accurate, giving clear information on events, and reviewed regularly. Staff must not start work at the home until their CRB form has been submitted and POVA First, or full CRB clearance has been received. The home must be in receipt of paperwork to validate identity, and applicants full employment history, before they start work at the home. To ensure the safety of residents and staff, all incidents where either party has hurt themself, or involved in a fall, must be recorded. All incidents should be investigated, and action taken to reduce the risk of another incident happening. Timescale for action With immediate and ongoing affect. Immediate 2. 7, 8, 37 15,17 3. 29 19, (1) (b) Immediate 4. 29 15 (2) (b) Immediate 5. 37, 38 13 (4) 17 With Immediate and ongoing affect. St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 23 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 2 Good Practice Recommendations The home needs to review all the information given out to resident’s to ensure it is up to date and informative. This should include full information on the home’s complaint procedure, and reference to the ‘Fire Officer’s annual visit taken out, and reworded to reflect actual practice. To ensure that residents are given the level of local information that they would find most useful when moving into the home. Staff, including the Activity Therapist, should ask residents if they would work with them to produce the information pack. Residents should also be asked their views, on the format of the information pack, including the lay out, and size of print used. It would be more informative to the reader, if the contract clearly states if any charges are made, following the death of a resident. Information on who the home is registered with, should also be updated. The home should review all their residents, to ensure they fall within the registered category of the home. Where it is identfied that a residents mental health needs are changing, a review should be held, and advice sought from a specialist Health Care professional. The home should consult further with residents, to identfiy if the current activities and outings arranged by the home meets their interests/needs. The homes complaint procedure should make clear to people wishing to complain - that they can contact the CSCI at any stage. It is reccomended,that the homes complaint procedure, just gives details of the local (not regional) CSCI office, where the lead inspector is based. This would ensure when a complaint is received that the person dealing with the complaint has a working knowledge of the home. 2. 1 3. 2 4. 4,7 5. 6. 12 16 St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 5th Floor, St Vincent House 1 Cutler Street Ipswich Suffolk, IP1 1UQ 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 St Barnabas Residential Home I54-I04 S24494 St Barnabas V228096 050617 Stage 4.doc Version 1.30 Page 25 - 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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