Care Home: Barlavington Manor

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What the care home does well The accommodation provided is of a good standard. The atmosphere in the home was relaxed and staff were cheerful and very helpful; they were attending to people in a sensitive and caring way. There is a thorough recruitment process and a good training programme. Staff said that they are well supported and that the manager is available and encouraging. The food is of a high standard and the dining rooms are attractively laid out so that people have a pleasant place to eat.The home continues to have good links and relationships with other health professionals including the local GP and district nurses. Comments made by people who returned surveys include: "The staff here are very friendly and of help for a wide range of needs. I am very pleased to be here", ""When I need support the staff always help me", "Barlavington Manor is a clean, safe environment and service users appear to be well looked after", "The home provides a friendly, comfortable environment for residents. Staff make good efforts to get to know the residents well and meet their different individual needs" and "Provides a good varied and nourishing diet in restaurant like surroundings". What has improved since the last inspection? The two requirements made at the previous inspection have now been met. The fire officer has been consulted and there are safety door closures in all rooms. A new sprinkler system has been fitted to protect better people in the event of a fire. New staff do not begin in post until a Criminal Record Bureau (CRB) check has been received. All staff have attended mandatory training. Staffing levels have increased in the main building and in the North Wing. What the care home could do better: The management team must ensure that they have carried out and documented a comprehensive assessment of a person`s needs before they move to the home to make sure that a plan of care can be drawn up when they arrive. For people who have a dementia there should be a record of how their move is planned to assist them to adjust to the move and settle in more easily. It is recommended that care plans should be more person centred and include details of the person`s previous lifestyle, interests, preferred daily routines and spiritual or cultural needs and wishes. The monthly visits made by the registered individual should be recorded and kept in the home. CARE HOMES FOR OLDER PEOPLE Barlavington Manor Burton Park Road Heath End Petworth West Sussex GU28 0JS Lead Inspector Annette Campbell-Currie Unannounced Inspection 13th March 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barlavington Manor Address Burton Park Road Heath End Petworth West Sussex GU28 0JS 01798 343309 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) amanda@barlavingtonmanor.co.uk Realmpark Health Care (Petworth) Limited Miss Lisa Ryan Care Home 64 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (21), Old age, not falling within any other category (43) Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 21 (Twenty-one) persons in the category MD(E) to be accommodated A maximum of 21 (Twenty-one) persons in the DE(E) category to be accommodated A total of 64 service users may be accommodated at any time. Date of last inspection 25th May 2006 Brief Description of the Service: Barlavington Manor is a Care Home, standing in extensive, well cared for grounds, in a rural area near Petworth. It is owned by Realmpark Healthcare (Petworth) Limited. The main house is for forty-three service users in the category of Older People. In addition to this there is separate extended accommodation for service users with dementia. This unit provides en-suite accommodation for twenty-one service users making a total of sixty-four service users. Separate entrances, reception offices, car parking and communal areas are provided for each category of registration with a security system for the service users with dementia. The responsible person on behalf of Realmpark Health Care (Petworth) Ltd is Mr Lawrence Harvey and the registered manager is Ms Lisa Ryan. The current fees are from £600 to £725 and the Dementia Unit £775 per week. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is Two Star. This means that the people who use this service experience good outcomes. Annette Campbell-Currie carried out the site visit for this key unannounced inspection over six and a quarter hours. Two requirements had been made at the previous inspection. The manager has taken action to make sure the requirements have been met. The outcomes for people living in the home were assessed in relation to twenty-three of the thirty-eight National Minimum Standards for the care of older people, including those considered to be key standards to ensure the welfare of people living in the home. The manager assisted with the inspection and the staff on duty were very helpful; all the information and paperwork needed was available. There were thirty-three people staying in the main building and twenty-one in the North Wing; one person was in hospital and another person was admitted during the course of the day. The manager had returned an annual quality assurance assessment form (AQAA) about the home and this was used in the planning of the inspection. Comment cards about the service were received from twenty-two residents, nine staff, two relatives and four health care professionals. The information has been used in making an assessment of the service. The following documents were read: the case records for six service users, recruitment records for four recently appointed staff, training records, quality assurance information and other relevant information. During the day four residents, six members of staff and a district nurse were spoken with. The two requirements regarding seeking the advice of the fire officer and need to operate a robust recruitment policy have now been met. What the service does well: The accommodation provided is of a good standard. The atmosphere in the home was relaxed and staff were cheerful and very helpful; they were attending to people in a sensitive and caring way. There is a thorough recruitment process and a good training programme. Staff said that they are well supported and that the manager is available and encouraging. The food is of a high standard and the dining rooms are attractively laid out so that people have a pleasant place to eat. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 6 The home continues to have good links and relationships with other health professionals including the local GP and district nurses. Comments made by people who returned surveys include: “The staff here are very friendly and of help for a wide range of needs. I am very pleased to be here”, “”When I need support the staff always help me”, “Barlavington Manor is a clean, safe environment and service users appear to be well looked after”, “The home provides a friendly, comfortable environment for residents. Staff make good efforts to get to know the residents well and meet their different individual needs” and “Provides a good varied and nourishing diet in restaurant like surroundings”. 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. The summary of this inspection report can be made available in other formats on request. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 (Standard 6 does not apply) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have the information that they need to make a decision about moving to the home. The assessments carried out before someone moves to the home should be more detailed so the home can be sure they will understand and meet the person’s needs. People who are able to, have the opportunity to visit the home before they decide to move. EVIDENCE: There is a Statement of Purpose and Service User Guide that is provided in a folder and kept in people’s rooms in the main building. People interested in moving to the home are given a glossy brochure and a welcome pack of information when they arrive. The documents have been reviewed and updated since the previous inspection. Seventeen of the twenty-two people who returned comment cards said that they had received enough information about the home before they moved in. The manager was advised to consider ways to Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 9 make information about the home more accessible to people who have a dementia and are moving to the North Wing. The deputy managers for the main house and the North Wing carry out an assessment of each person’s needs before they move to the home. Sometimes this is carried out by phone if the person does not live in the immediate area. It was clear that family members are often involved in helping people to make a decision about moving to the home. There is a pre-admission form that is completed by staff and family members are given a full assessment form that includes detailed information about the person’s needs, life history, preferred routines, religious wishes and interests. The manager said that often these forms are not returned and therefore the information the home have about the needs of the person is not detailed. Samples of case records were seen in both parts of the home. One of the three case records seen in the dementia unit included an assessment that had been fully completed by relatives and provided a great deal of information so that the staff could be sure the home could meet the person’s needs and draw up a detailed plan of care when they arrive. There was little detail on the assessments carried out by the staff, which did not provide a holistic view of the person, and there was no evidence that people had been involved in their assessment. For one person who had moved to the North Wing the previous day there was information from a previous care home but no evidence to show that an assessment had been carried out by the home so that they could be sure the person’s needs would be met. There was no plan to assist the person in the moving process and no plan of care so that staff would know her immediate needs on arrival. It is recommended that the manager review the preassessment process to ensure that detailed information is gathered before a decision is made about the person moving to the home to make sure their needs could be met. There should be evidence to show that the person has been involved in their assessment. The deputy manager provided an example of when during a pre-assessment she felt the home would not be able to provide a sufficient level of care for a person who needed a lot of help with mobility. The manager said that people are welcome to visit the home before they decide whether or not to move in. It was clear that relatives are often involved in this decision. In the North Wing it was not clear that people have had the opportunity to visit the home before they move. There was no written evidence to show that there was a planned admission for people moving to the North Wing including the person who had moved the previous day. As this is a specialist unit for people who have a dementia it would be expected that written evidence of the planning for how an individual should be supported on admission should be in place. A record of the actual support a resident Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 10 received on admission with a regular monitoring noting how that individual is settling into the home should also be in place. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are set out in a plan of care. People’s health needs are very well met. The home’s policies and procedures regarding medication ensure that people would be protected. People are treated with respect and their right to privacy upheld. EVIDENCE: There is a standard format for care planning that includes a sheet for documenting people’s personal goals. The forms include space for all aspects of each person’s daily needs to be recorded and any risks to their wellbeing noted. The care plans are kept in the offices in each building so that care staff can access them and keep them updated on a regular basis so that any change of need is clear to all staff. Contact with health professionals such as GPs, district nurses and the chiropodist are recorded and key events are recorded daily. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 12 The case records of six people were seen and five included information about their care needs and how care should be provided. The goal sheets included some information about people’s wishes. Comments on one goal sheet were: “to encourage personal hygiene and to keep physically and mentally as active as possible” however there was no guidance about the way that staff should assist the person to meet their goals. The detailed pre-assessment forms seen on two of the six case records and that had been completed with the assistance of relatives included a great deal of detail about the person’s background, preferred lifestyle, interests and hobbies and spiritual and cultural wishes. There was little information on the other four. The person in the North Wing who had moved in the previous day had no initial care plan drawn up so that staff would know her basic care needs until a more detailed plan could be drawn up. There was evidence to show that care plans had been reviewed monthly. Risk assessments had been carried out in trips and falls, mobility, nutrition and skin integrity. In the North Wing risk assessments included the risk of wandering, infection, pressure sores, choking, burning or scalding. Risk assessments had been reviewed monthly. The staff who compile the care plans should ensure that a person centred approach is taken so that people know their personal and social care needs will be met. The home has a good relationship with the local primary care team. A GP visits weekly and two district nurses visit twice a week. During the day the GP was consulted about the health needs of people who were unwell which resulted in one person being admitted to hospital for the treatment she needed without delay. One of the district nurses was spoken with and she said that the manager and staff are very pro-active in seeking the health care that people need. She said that the staff follow guidance that is provided and communication between them is good. Medication reviews are carried out by the GP or psychiatrist on a regular basis to ensure that people are receiving the medication that they need. The case records that were seen included information about the health care that people needed and visits from the GP or district nurses were documented. People had been weighed on admission to the home and their weight monitored monthly. There are medication policies in place and staff who administer medication have attended training in the safe handling and administration of medication. The person who was administering medication in the North Wing said that a local pharmacy provide regular updates so that staff have the current knowledge they need about medicines. The member of staff was clear about the recording and administration process. Lockable space is available for people who are able to self-medicate. Staff are provided with guidance about the way to provide personal care as part of their induction. Staff spoken with said that they understand the care that people need. Staff were observed to be providing care in a sensitive and respectful manner. People in the main house who were spoken with said that staff are good and that they receive the care that they need. Twenty-one of Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 13 the twenty-two people who returned surveys said that they always or usually receive the care that they need and all said that staff listen and act on what they say. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People usually find their lifestyle experience in the home matches their expectations and preferences. People are supported to maintain contact with relatives and friends. People are usually supported to make choices in their lives. A wholesome, appealing balanced diet is provided in pleasing surroundings. EVIDENCE: There is a range of activities available in the home including musical exercise, quizzes and arts and crafts. A hairdresser comes twice a week and there is a shop available for basic purchases. There is currently no activities coordinator to increase the range of activities available and to make sure people have an individual programme that suits them. Sixteen people who returned surveys said that there are always or usually activities arranged by the home and six people said there are sometimes activities. There were no planned activities available during the day of the site visit. The people spoken with in the main house said that they are supported to pursue their interests and hobbies; one person is an artist and is encouraged with her painting. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 15 The deputy manager in the North Wing said that in the afternoons one to one sessions with care staff are provided. One person was having her fingernails varnished during the morning. There are some games available for people to play with support from staff. There was little detail about people’s previous lifestyle and interests on the case records seen so that an individual activities programme could be drawn up. The arrangement of the chairs in the communal area was discussed to find ways to make it easier for staff to arrange activities for people in small groups. There were completed social programme forms on some case records; these included hairdressing and chiropody visits and in one case massage sessions. The district nurse visits the home twice a week and said there is always something going on for people to do. There is no dedicated transport for the home for people to use on a regular basis. A minibus is hired every Tuesday afternoon so that some people can go for outings. The manager said that there is a plan to purchase a vehicle for this purpose. People are supported to maintain contact with their relatives and friends. During the day several people were going out with their families and one person said their visitors are always made welcome. Both relatives who returned surveys said that the home helps them keep in touch with their family member. People are supported to make choices for themselves when they are able to. It was clear that people in the main house are encouraged and supported to make choices in their lives. The people spoken with said they could choose the way they prefer to spend their days. Pets are welcome in the home and several people had brought their pet with them to the home. In the North Wing the staff said they show people items to help them make simple choices for example whether they wish to have tea or coffee. The possibility of using photographs or picture cards to help people who have a dementia to make choices in their daily lives was discussed with the manager and deputy manager who runs the unit. There is a varied menu that is displayed and a choice of meal is offered. People’s nutritional needs and wishes are noted on their case records. Allergies and special requirements are catered for. The majority of people who returned surveys said that they always or usually like the food. The meal being served at lunchtime was home cooked and appetising. The dining rooms are pleasant and the mealtime in the North Wing was relaxed and quiet. It was not clear how people in the North Wing are supported to make choices about the food they would like. The manager was advised to ensure that people who are being assisted with eating should have the full attention of the member of staff with a discussion about the food they are having. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 16 Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaint will be listened to and acted upon. People are protected from possible abuse by the policies and procedures that are in place. EVIDENCE: There is a complaints policy that is provided to everyone who lives in the home. Twenty-one of the twenty-two people who returned surveys said they knew how to make a complaint and people spoken with said they were confident that their concerns or complaints would be listened to. There is a system for recording complaints however none have been received since the last inspection. The Commission has not received any concerns or complaints about the home. There are policies and guidance to staff about safeguarding adults. Training records were seen and showed that all staff have received training in adult abuse. The staff spoken with understood their duties in reporting any allegations or concerns that abuse may have occurred. The recruitment process has been improved so that staff do not begin work until a Criminal Records Bureau (CRB) check has been received. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 18 Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe and well-maintained environment. The home is clean pleasant and hygienic. EVIDENCE: The accommodation and communal areas are well furnished and decorated. There is a programme of maintenance and the annual quality assurance assessment completed by the manager shows that the building and equipment is maintained and serviced as required. The home is clean and bright. There is a team of domestic staff who ensure that home is kept clean. Everyone who returned surveys said that the home is fresh and clean. There is a development programme and a new reception and office area is due to be built in the near future. The grounds are well maintained and provide a pleasant space for people to use in good weather. The main house has views over the Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 20 surrounding countryside and several people said that they like going for walks with the help of staff. In the main house there are several communal lounges and areas where people can sit in small groups if they wish to. The North Wing has been purpose built and provides accommodation for people who have a dementia. The building is light with a wide corridor to the lounge area. People have their names on their bedroom doors. It was suggested that consideration should be given to providing visual ways to help people who are confused recognise their rooms and toilet, bathroom and other facilities in the building. The laundry facilities are suitable for the needs of the home with personal laundry being washed on the premises. Heavy or soiled laundry is not washed on the premises. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are met by the numbers and skill mix of staff. People are protected by the home’s recruitment policy and procedure. Staff are trained and competent to do their jobs. EVIDENCE: Staffing rotas showed that there were adequate numbers of staff on duty in both areas of the home. People were being assisted in an unhurried manner and those spoken with said that staff are available and provide the support and care that they need. Twenty-one of the twenty-two people who returned surveys said that staff are available when they need them. Call bells were being answered without delay. People were being well cared for. The manager said that staff are encouraged and supported to achieve the National Vocational Qualification (NVQ) level two and three award in care. Seventeen of the fifty care staff have achieved the award and five are currently studying for the award; this does not yet meet the target of fifty percent of care staff achieving the NVQ level two or above. The home has a recruitment policy and all prospective members of staff complete an application form and have an interview with the manager. The Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 22 recruitment records of four recently appointed members of staff were seen and showed that all the required checks had been carried out before the person began in post. The manager said that gaps in employment would be discussed during the interview and references are always sought from the previous employer. The Criminal Records Bureau (CRB) and Protection of Vulnerable Adults Register are checked before someone begins in post. The manager said that due to the rural area of the home it is difficult to recruit staff. A local agency is used for additional staffing cover. The home has a good relationship with the agency and ensures that all staff they supply are fully checked before they begin work. There is an induction and training programme. The induction covers key policies and a new member of staff shadows more experienced staff when they begin work. It was suggested that a more structured induction programme should be provided in line with the Skills for Care guidance. The manager said she would consider implementing this programme. Staff training records were seen and showed that there is an efficient system for ensuring that staff have completed the mandatory training and updates as required. All staff now receive three paid days training each year. The manager said that no staff would be involve in providing care for people who have mobility problems before they have completed a moving and handling course to ensure that the resident and member of staff are kept safe. The staff who provide dementia care have attended specialist training so that they understand the needs of people in their care. Staff spoken with said that they are supported to attend training courses. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a well managed home and their views are listened to and respected. People’s financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Lisa Ryan is the registered manager of the home and has been in post since June 2006; she was previously managing the North Wing for people who have a dementia. Ms Ryan is committed to her ongoing training and attends some courses with staff so she is aware of their knowledge and skills. Ms Ryan said that the proprietor is very supportive and meets with her regularly. She said that she is not restricted by budgets and is able to develop the home and Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 24 purchase new equipment as required. Two deputy managers have responsibility for the day-to-day running of the main house and the North Wing. There is a quality assurance system in place. There were copies of completed questionnaires on file from people living in the home and their relatives. The information has not yet been collated and published. Feedback from the surveys sent out by the Commission indicated that people know who to talk to if they have a concern and that they feel listened to. There are regular residents meetings for those who are able to take part and a monthly newsletter is provided so that people can keep up to date with planned events and developments. The proprietor visits the home regularly however these visits should be recorded as required under Regulation twenty-six of the Care Standards Act 2000. The home do not get involved in helping people to manage their finances or hold money for them. Relatives or solicitors support people living in the home with their finances. The necessary policies and systems are in place to ensure the safety of people living in the home and the staff who work there. The manager said the requirements of the fire officer and the environmental health officer have been met. The doors all have safety closures to make sure that people would be protected in the event of a fire. A new sprinkler system has been fitted to provide additional protection in the event of a fire. Equipment is services as required. All staff have attended mandatory training to ensure they understand how to keep themselves and others safe. A record is kept of accidents and incidents so that these can be monitored and precautions put in place if necessary. Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Barlavington Manor DS0000014386.V359158.R01.S.doc Version 5.2 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. 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