Inspection on 06/12/05 for St Barnabas Residential Home

This inspection was carried out on 6th December 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.

Other inspections for this house

St Barnabas Residential Home 18/04/07

St Barnabas Residential Home 24/04/06

St Barnabas Residential Home 17/06/05

St Barnabas Residential Home 28/02/05

St Barnabas Residential Home 29/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Barnabas Residential Home The Common Southwold Suffolk IP18 6AJ Lead Inspector Jill Clarke Unannounced Inspection 6 December 2005 11:20 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 St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Barnabas Residential Home Address The Common Southwold Suffolk IP18 6AJ 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) 01502 722264 The Trustees Wendy June Clack Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th June 2005 Brief Description of the Service: St. Barnabas is set in the residential area of Southwold, a short walk from the town centre, with its range of amenities. These include beaches, shops, restaurants, coffee shops, banks and post office. Public transport links include 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. Due to the limited space in the passenger lift, not all people who use a wheelchair can be accommodated on the first floor. All 13 bedrooms have their own wash hand basin, 3 also have en-suite 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 an enclosed courtyard, and gardens which face out to the Common and sea front. There is off road parking at the side of the home, with further public car parking available, a short walk away. The home is a no smoking home. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of 2 routine regulatory inspections, undertaken between 1 April 2005 and 31 March 2006. The inspection undertaken by the Lead Inspector for the home, took place over 6 ¼ hours, on a Tuesday in December. The aim of this inspection was to look at relevant standards, which had not been looked at during the first inspection undertaken on the 17 June 2005. Time was also spent ensuring that requirements and recommendations made following the last inspection had been addressed. During the inspection, time was spent talking to 7 residents in private, to hear their views on what it was like living at St Barnabas. General feedback from discussions with residents was obtained throughout the visit. Time was spent with 4 members of staff, which included the Manager, Chairman of the Trustees, and Carers. A tour was made of all the communal accommodation, 2 toilets, 2 bathrooms, and a sample of 3 bedrooms, to check the condition of the décor, furniture and hot water temperatures. Records inspected included care plans, medication record, Statement of Purpose, recruitment paperwork and staff rotas. Discussions during the day with people living at the home, and staff, identified that they preferred to be known as residents, rather than service users. This report respects their wishes. What the service does well: What has improved since the last inspection? Staff are now carrying out their own pre-assessments, to ensure that they can meet the level of care the prospective resident is looking for. New staff are not allowed to start work in the home, until all required checks and information has been obtained. Care plans have been updated, and the change of management has not affected the running or the atmosphere of the home. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 6 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 DS0000024494.V274525.R01.S.doc Version 5.1 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 St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 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 the following standard(s): 1, 2 and 3. (Standard 6 not applicable). People wishing to move into the home, can expect their needs to be fully assessed. This ensures that the home only admits residents within their registration category, whose care needs they can meet. EVIDENCE: Standards 4 and 5 were assessed as met during the last routine inspection carried out on the 17/6/05. The new Manager took up post in July 2005, and has since been working to address the recommendations made in the last report (17/6/05). This included reviewing all the information given in the Home’s Statement of Purpose and Residents Guide, to ensure it is accurate, up to date and in an easy to read format. The manager showed the work undertaken so far, which is near completion. During the last inspection it was recommended that the home include in their ‘Terms and Conditions of Residency’, clear information on any charges made following the death of a resident. A copy of the new contract was looked at, which stated ‘ fees will remain payable until the late resident’s effects have St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 9 been removed from the room’. The contract also includes information that all admissions are subject to a 4-week trial period. Concerns were raised at the last inspection that the home was not always undertaking their own pre-admission assessment. This made them reliant on other people’s information, who would not have a working knowledge of the level of care St Barnabas is able to offer, and registered to care for. There had been 1 new resident admitted since the last inspection, their file contained a Social Care assessment. The home had not undertaken their own assessment on this occasion, as the resident was already well known to them, as they attended Day Care at the home. They had used their day care assessment, and on-going records, to form the basis of the residents care plan. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 11. People using the service can expect their wishes concerning their personal care to be written in a care plan, and monitored. The homes current system of recording, storing and dispensing residents medication is unsafe, and could potentially put residents at risk. EVIDENCE: The manager had been reviewing all the care plans, to ensure that concerns raised during the last inspection had been addressed. Two of the residents care was ‘tracked’ during the inspection, which included talking to the residents, reviewing their care records (care plans), and discussing with staff the level of care/support given to the resident. Care plans gave guidance to staff, on the level of care the residents required. The different coloured ink used, and style of hand writing showed that the information had been updated and expanded on, however these entries were not signed or dated to be able to give clear information on the residents changing needs, and who had made the entries. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 11 Care plans held a daily report written by staff, which included information on how they may be feeling, and if they had any concerns over their welfare. Although staff had dated and signed the entries, some staff were leaving a line between entries. Concerns were raised that in leaving gaps, someone could write further information at a later date, but it would look like it had been recorded at the time. A resident whose care was being tracked was asked if it would be alright if they looked at the care plan together. The resident said that they “didn’t know” that they could look at their care plan. There was no record made in the care plan indicating how often the residents looked at their plan, and discussed its contents with staff. However, the Manager confirmed that staff sit and go through the residents care plan with them on admission. This led to discussions over some of the wording in 1 care plan, which staff said was the resident’s own observation of themselves – although it was not signed to state this. The resident felt the information contained in the care plan, reflected the level of support they were given. Further discussion identified that the resident was concerned that they were losing weight. Their Care plan did not hold an assessment tool, used to monitor resident’s weight, to support staff in identifying any problems. This was fed back to the manager, who had information on the ‘Malnutrition Universal Screening Tool (MUST)’, but had not started using it. The resident confirmed that they see a private chiropodist every 6 weeks, and they were visited by the “Red Cross hands and nails care”, once a month. The community nurse visited residents during the inspection, to redress wounds/ulcers and give care as required. Residents prescribed medication is dispensed (where applicable) from the Pharmacist, in dossett boxes. Where medication is unable to be dispensed into the dossett boxes, the medication is sent in its original box/bottle, or pharmacist container. Not all the dossett boxes were sealed, which could lead to medication falling out when using the container. Staff confirmed that although a majority of the dossett boxes come with security seals, which are not broken until the staff dispenses the medication, this was not always the case. Staff sign or entered a code on the Medication Administration Record (MAR) sheet, to confirm that they had given the medication to the resident, at the required time. October’s MAR sheets were looked at, and identified 4 missing signatures, although other medication given at the same time had been signed. The manager felt that staff would have given the medication, but forgotten to sign. Due the medication being dispensed from the Pharmacist in dossett boxes, which are returned weekly, this could not be checked. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 12 During the inspection a member of staff was observed removing the lunchtime medication from the cupboard, which included liquid medicines, which had already been dispensed into medicine pots. Concerns were raised that staff were preparing medicines for others to give out, which could lead to errors being made. Dossett boxes and liquid medications were carried around the home, instead of being transported in a lockable container. Records showed that staff kept a ‘log’ of medication coming into the home, which could not be dispensed from dossett boxes. The home was informed that they must keep a record of all medication received into the home. The inspector tried to undertake a check of a resident’s antibiotic, to ensure the right amount had been given. This was made impossible, as the medication had not been booked in by the home. A check of the records (MAR) against the expected amount of tablets that should have been left, did not agree. Staff were unsure if a second box had been delivered to the home, but remembered giving the medication to the resident. Staff were asked to take immediate action (see statuary requirements made). The home kept a range of ‘homely’ remedies, of over the counter medicines, to give to residents if needed. Concerns were raised over the range, age and where the medication came from. They included Nystatin suspension (which expired May 2005), a bottle of aspirin, with the name of a resident crossed out and the date torn off, and cough mixture, which expired in June 2003. This was not acceptable. The home was asked to remove all the medication, which was out of date, and was not official, over the counter medication. To support the new manager they were given information on obtaining a copy of the Royal Pharmaceutical Society of Great Britain guidelines for the administration and control of medicines in care homes and children’s service. Eye drops, which have a short shelf life of 28 days when opened, should be marked to state when the container was opened, to guide staff in knowing when to stop using the drops. This had not been undertaken. The home needs to ensure that staff have clear guidelines in the safe administration of medication, including actions to be taken if medication given in error, the use of homely remedies and procedure for residents who wish to look after/administer their own medication. After completing the last inspection (17/6/05), relatives of a resident who had recently passed away, approached the inspector in the car park, as they wanted to give feedback. They praised the staff, which had supported them during, and after the bereavement. They praised the standard of care, and support given, not only to the resident, but also to them as a family. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. People using the service can be expect to be treated with respect, and supported to exercise choice and control over their lives. EVIDENCE: Standards 12, 13 and 15 were assessed as met during the last routine inspection carried out on the 17/6/05. However, staff were asked (standard 12) to consult further with residents over the choice of activities and outings they would like to be involved with. Minutes of residents meetings viewed, and records held, showed that the home had consulted residents, and were trying to ensure that all residents’ interests were catered for. Time spent with a resident confirmed that they were able to do as they wanted – although they felt the staffing numbers at times restricted them from going out when they wanted. During the afternoon, time was spent in private with 6 residents, who jointly gave feedback on what it was like living at the home. During the informal residents meeting, they were asked if living in a care home restricted them from doing what they wanted to do, they replied “no”. The residents discussed how they had come to live at the home, and were pleased that they had been offered a place. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18. People using the service can expect any concerns are listened to, and appropriate action taken. However, the home must update their Abuse policy to reflect local protocols. EVIDENCE: The home’s complaints policy was assessed during the last inspection (17/6/05) as nearly met. A recommendation was made that the ‘home’s complaint procedure should inform the complainant that they could contact the CSCI at any stage of the complaint process. During this inspection, the complaints policy showed that the home had amended the policy, to reflect the recommendation. A copy of the home’s updated complaints procedure, was displayed in the entrance hall, and contained in the home’s Statement of Purpose. Discussions with residents confirmed that they would be happy to address any concerns directly with staff. During the last inspection, although not fully assessed, interviews with staff confirmed that they were aware of their responsibility in reporting any concerns over abuse, and that they had watched the ‘No Secrets’ video. The home’s written abuse policy made reference to reporting any concerns/abuse to a contact number in Lowestoft. This led to discussions that the home should be making Vulnerable Adults Referral through Customer First, or if applicable the police. It was also noted that the home did not have a copy of the Vulnerable Adult protection Committee (Suffolk) – Inter-Agency Policy Operational Procedures St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 15 and Staff Guidance – June 2004. The home was given information on where they could obtain a copy of the guidance. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, and 26 (second review). People using the service should expect a clean, homely environment, which meets their needs. EVIDENCE: Standards 20, 23, 24 and 26 was assessed as met during the last routine inspection 17/6/05. The environmental tour identified that some furniture (although service able) and paint work evidencing wear and tear. The main green carpet in the entrance hall, corridors and stairs, had what looked like a pink stain. Further investigation and discussion with staff identified that the carpet was worn (which gave the pink glow), but was clean and serviceable. There was no maintenance plan for the home, but the manager said that they had started completing a maintenance book to evidence what work they had undertaken. They said that they would approach The Trustees for any items that needed replacing, and bedrooms are routinely decorated when they become empty. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 17 The homes laundry is located outside, and can only be accessed by going through the residents’ dining room or kitchen. The Trustees are aware that the location of the laundry is not suitable, and have plans to move the laundry, if they are able to raise the funds to undertake planned building works (see report dated 17/6/05). Staff confirmed that they do not take laundry through the dining room when residents are eating, and linen is always transferred in a sealed plastic bag. Noticing bowls in the laundry, staff was asked if they soaked laundry. They replied “yes”, that they would “sluice” the faeces, and soak the item in a bowl. This led to discussions that as part of the home’s infection control procedures (to stop any chance of infections being passed around the home), clothing soiled with bodily fluids (blood, faeces, vomit) should not be soaked. It was also identified that care staff could be using a nailbrush, which as part of the homes infection control policy – should also not be used. Residents asked if they felt the laundry service at the home was good?, replied “very good”. One resident went on to say that they had “never lost anything”, that “staff take clothing away – and it comes back lovely”. During the meeting residents confirmed that the home was kept warm, and that they “never find “ the hot water “too hot”, with 1 resident saying it was “just right”. Residents said staff kept the home clean, and no concerns were raised over any unpleasant odours. Whilst walking around the home areas was found to be clean, except for an extractor fan in an upstairs bathroom. This was reported back to the manager, who said that they had just taken on a new domestic, and they had on their job list to check and clean all the extractor fans. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 (second review). People using the service can expect to be cared for by staff, who have undergone robust employment checks – prior to them starting work at the home. EVIDENCE: Standards 27, 28, and 30 were assessed as met, and standard 29 as nearly met, during the last routine inspection carried out on the 17/6/05. During the last inspection concerns were raised that the home was not always following safe recruitment procures, by not fully checking a persons identity prior to them starting employment. Since the new manager took over, they have recruited 1 member of staff. Their records were checked which showed that the home had followed safe recruitment procedures, and all required paper (references, POVA First Clearance and paperwork to validate identity) had been obtained. The manager had also produced a recruitment check list and recruitment policy to ensure all staff followed the same safe procedures when recruiting staff. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 37 and 38. Although the home is committed to providing a good level of care, they are potentially putting residents at risk by not always following safe manual handling procedures. EVIDENCE: Standards 32 and 33 was assessed as met, and standards 37 and 38, as nearly met during the last routine inspection 17/6/05. Following this inspection the new Manager Mrs Clack, attended (12/12/05) the CSCI office for their Fit Persons Interview (FPI), which resulted in the recommendation being made, for Mrs Clack to become registered as a manager, with the CSCI. Mrs Clack is experienced in care, and has worked at St. Barnabas since 1998. Following the retirement of the previous manager Mrs Reeves. Mrs Clack was promoted from Deputy Manager, to Homes Manager in July 2005. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 20 Mrs Clack has completed her NVQ 4 in Care, and holds a City & Guilds – Advanced Management for Care Award. Throughout the inspection and FPI, Mrs Clack demonstrated a commitment to provide a good level of service, and to work co-operatively with the CSCI too ensure the home meets the National Minimum Standards. The system the home had in place for holding residents monies, which had been handed in for safekeeping was checked. Money was held in a lockable container, which had restricted key access. All deposits or withdrawals had been recorded in the resident’s own ‘personal monies and property book’. A sample of 2 resident’s books was checked, against monies held and was correct. The record book showed that both the manager and resident had signed any transactions. The homes Fire log book showed that 20 staff had attended a ½ day Fire lecture and practical training, undertaken by an out provider. Although staff said that the fire alarm systems were checked weekly, their was no record after the 14 November of the alarms being tested. Records showed that the emergency lighting was being checked 3 monthly instead of monthly, in line with Suffolk County Council (SCC) Fire Service guidelines. The home was asked to look at the SCC ‘Test methods and frequency for Fire Safety provisions’ to ensure that they carried out the checks as listed. A copy of the homes fire procedures for staff and residents was looked at. A copy of the fire procedures was also displayed in resident’s bedrooms. The home was asked to ensure that visitors were also made aware of what action they should take, which could be displayed next to the signing in book. The manager stated that some relatives had said that they did not see why they had to sign the visitor’s book. This led to discussions over the requirement to keep a record of all people visiting the home, and safety element, that during a fire, the fire officer would need to know who was in the building, to be able to rescue them if necessary. The home had no evacuation plan, which would be required if the home had to move residents out in an emergency. The home had a full Fire Risk Assessment undertaken during March 2005, by an outside contractor. The risk assessment contained recommendations to improve the safety of the home. Although the Manager said that a member of the Committee (Trustees) had reviewed the report and taken appropriate action, it was not recorded on the main risk assessment. During the last inspection it was identified that the home was not always completing incident forms, and undertaking a follow up investigation. Care St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 21 plans showed that this was now happening. However, shortfalls were still identified in the recording of homes medication (see Health and Personal Care) and Fire Records. Prior to the evening meal, staff started assisting residents to the dining room. One resident who was recovering their mobility after medical treatment, was being transferred in a wheelchair. The resident was trying to hold their feet up, as staff were not using any footplates. The manager intercepted straight away, however this resulted in the wheelchair having to be pulled backwards into the dining room, to reduce the risk to the resident. The manager confirmed that the staff had received manual handling training. An immediate requirement was made to ensure residents were transferred safely, using footplates – unless otherwise stated in their care plan and risk assessment. St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X 2 2 St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4, 5 Requirement Timescale for action 01/03/06 2 OP9 13 (2) The home must complete their Statement of Purpose and Residents Guide, and make copies available to residents, and their representative. A copy should also be sent to the CSCI. The home must have safe 06/12/05 systems in place to record all medication coming into, and out of the home. The expiry dates of all homely medications must be checked to ensure that they are still in date. 06/12/05 3 OP9 13 (2) (4) 4 OP9 13 (5) To reduce the risk of any errors, 10/12/05 the home must stop the practice of preparing liquid medications in advance. The home must use previously 06/01/06 prescribed medications for residents, as part of their homely remedies. Any medication no longer required by the resident, must be returned to Pharmacist or disposed of as given in current guidelines. 5 OP9 13 (2) St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 24 6 OP9 13 (2) (4) The home must write to the CSCI to state what action they are taking to ensure that medication (dossett boxes and liquid medication) being taken around the home, is transported safety. The home must ensure that residents are transferred safely in their wheelchair. Footplates must be used – unless otherwise stated in the resident’s care plan – including any risk assessments. The home must review their Fire policy to ensure checks are undertaken as given in the Suffolk County Council ‘Test methods and frequency for Fire Safety provisions’ booklet. All checks undertaken must be recorded in the book, to evidence that it has been completed, and any required action taken. 01/02/06 7 OP38 13 (5) 06/12/05 8 OP38 23 (4) 14/01/06 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 OP7OP8 Good Practice Recommendations It is recommended that all entries in residents care plans are dated and signed, to give a clear indication of any changes to resident’s health, and who had made the entry. The home should look at introducing a nutrition monitoring tool, such as MUST, to support them in monitoring and taking appropriate action when required, relating to DS0000024494.V274525.R01.S.doc Version 5.1 Page 25 2 OP8 St Barnabas Residential Home residents nutritional needs. 3 OP9 The home should liaise with the dispensing Pharmacist to ascertain why some dossett boxes sent to the home are sealed, whilst others are not. The home should try and ensure, all boxes are sealed, to reduce the risk of medication falling out of the dossett box, when dispensing medication. To ensure staff know when preparations, which have a short shelf life once opened, are still in date – staff should date the container to confirm when opened. The home, after obtaining and reading the ROSPA ‘The Administration and Control of medicines in Care Homes and Children’s Services’ – look at their current homely medicines, and ensure they meet the criteria, and have been purchased as ‘over the counter’ medication. The home should list all the homely remedies, and consult with the residents own GP, to ensure they are happy for the medication to be given if required, taking into account the residents current prescribed medications, and medical history. To ensure that staff follow local procedures for reporting Abuse, they should obtain a copy of the June 2004 Vulnerable Adult Protection Committee’s Inter-Agency Policy Operational Procedures and Staff Guidance. Once obtained, the home should review and amended their current guidelines/abuse policy to ensure all contact numbers and information given is correct. It is recommended that the Manager and Responsible Individual attend local vulnerable Adult Training, run by the vulnerable adult team, to ensure they are confident in what action they should be taking to reporting instances or concerns of abuse. To get an over view of the planned work being undertaken, it is recommended that the home keeps a maintenance plan, which gives details of all planned and on going maintenance work, including redecoration and any planned replacement of worn items. It is recommended that staff stop the practice of leaving an empty line between entries in daily records, to stop the chance of a entry being made at a later date, which could DS0000024494.V274525.R01.S.doc Version 5.1 Page 26 4 OP9 5 OP9 6 OP9 7 OP18 8 OP18 9 OP19 10 OP37 St Barnabas Residential Home change the emphasis/meaning on what has already been written. 11 OP38 The home should include in their Fire risk assessment, what action they have taken, following the recommendations made by the contractor who undertook their fire risk assessment. The home has printed fire procedures for residents and staff – they should also include what actions to be taken by visitors. 12 OP38 St Barnabas Residential Home DS0000024494.V274525.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House 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 DS0000024494.V274525.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!