Inspection on 11/01/06 for Barkat

This inspection was carried out on 11th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Barkat 01/05/08

Barkat 03/05/07

Barkat 22/05/06

Barkat 05/07/05

Barkat 19/01/05

Barkat 06/02/04

Barkat 19/08/03

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Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Barkat 254 Alcester Road Moseley Birmingham West Midlands B13 8EY Lead Inspector Jill Brown Unannounced Inspection 11th January 2006 09:05 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 Barkat DS0000016738.V277437.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. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Barkat Address 254 Alcester Road Moseley Birmingham West Midlands B13 8EY 0121 449 0584 0121 449 2726 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) Ms Seemia Butt Ms Shahnaz Butt Ms Seemia Butt Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home can accommodate up to three people under 65 years of age for reasons of mental disorder. All of the senior staff undertake a course in the management of challenging behaviour by January 2005. 5th July 2005 Date of last inspection Brief Description of the Service: Barkat House is a large detached property situated on the main Alcester Road in Moseley. It is within easy walking distance of the main shopping area of Moseley where shops, restaurants, public houses and churches can be found and a larger shopping area can be found by walking to Kings Heath. The home enjoys easy access to public transport routes leading to the city centre and beyond. Barkat House offers accommodation to 25 older people in single rooms on the ground and first floor. There is a passenger lift between the ground and first floor. Communal areas are located on the ground floor. There is a large lounge to the front of the house, a smaller lounge to the rear. Residents that smoke use the small lounge. The home has a separate dining room. The home has communal toilets and either an assisted bathing or a shower facility based on both floors. The ground floor also houses the kitchen, office, laundry and large storage area. The home has a dedicated garden for the use of service users. The home has a small amount of parking at the front of the building. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection took place over 3 and a quarter hours on a day in January. The home had an announced inspection in July of this year when all but one of the core standards were assessed. It is recommended that this inspection report be read with the July inspection report to get a fuller picture of the home. Three residents were spoken with, three residents case files and three staff files were viewed. A tour of the new areas of the building was undertaken. Requirements from the last inspection to: - not rush residents that needed assistance to eat, not put instructions to staff on resident’s chest of drawers, improve decoration of residents’ bedrooms and improve practice in the kitchen area were not assessed and were brought forward. What the service does well: What has improved since the last inspection? The owners of the home have been making improvements to the environment. The reception hall had been redecorated and new non- slip flooring had been laid. The smoking room had a new feature fireplace and a new toilet facility had been created off the main lounge. A pool table had been bought and there was evidence in residents’ daily records that residents were enjoying using this. The home has extended the property and two new bedrooms have been created these are not yet ready for registration. Barkat DS0000016738.V277437.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. Barkat DS0000016738.V277437.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 Barkat DS0000016738.V277437.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): 3 Assessments of residents needs were variable and this could mean that residents’ needs are not met. EVIDENCE: Assessments on resident’s health and social care needs were variable. A number of assessments contained good information on the residents. These showed preferred times of getting up, interests such as rock and roll as well as stating health conditions. Others had little information other than the person was dependent or independent. Assessments undertaken by the home were not dated so it was not possible to tell whether the assessments were undertaken at the pre admission visit, prior to the admission or after. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 9 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, 10 The arrangements for care planning had deteriorated since the last inspection and the lacks of plans in some instances puts residents at risk. Health needs were met. EVIDENCE: Where residents had care plans these were excellent however newer admissions did not have their needs translated in to plans of care. This means that staff were not given detailed instructions in how to care for the individual resident. Risk assessments were in place for all residents. The risk assessments were detailed containing information on the management on the use of alcohol, smoking and challenging behaviour where these were identified as issues for the resident. Aggression management strategies were in place where needed. Some consideration needed to be given to racist behaviour of one resident and how this could be managed. The home clearly records the contacts residents have with health professionals such as doctors, district nurses, opticians and so on. A monthly review of care received is documented. The home has clear records of when residents receive Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 10 or refuse assistance with bathing. It was clear that residents’ weights were taken routinely and where necessary plans were put in place to offer extra food. Medication administration was not assessed on this occasion but was good at a previous inspection and recommendations to further improve practice were brought forward. The home still had some care instructions on delivery of care on residents’ bedroom walls and this does make the room look homely. It was clear that residents are clear sense of ownership of the home. One resident coming and informing a manager that another resident needed assistance and another was quite happy to raise a concern with the manager whilst walking around the building. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 11 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): 12 Whilst activities and individual activities happened these were not in a planned way. This means that a number of residents needs for assistance to have activities could be missed. EVIDENCE: The manager said that they had not got planned activities in the home. There was evidence of a pool table; a number of residents enjoyed playing this and this was in their care plan. A resident liked to go out but needed escorting and there was evidence of this happening on the day of the inspection. One resident was making plans with the manager to go on holiday. A previous requirement about improving the way a resident was assisted to eat was not assessed and is brought forward. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: These standards were not assessed on this occasion although the requirement for staff to attend adult protection courses had not been achieved and was still outstanding. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 13 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, 26 Although the home had made improvements to the environment further improvements were required to improve the safety and decoration of the home. These improvements will increase safety and make a more comfortable place for residents. EVIDENCE: The home had extended the accommodation provided to residents. This has included two extra bedrooms, improving the laundry facilities, storage facilities and making 4 existing bedrooms into en suite rooms. The new bedrooms were still to be registered. In these bedrooms radiator covers were required, flooring in the en suite facilities and furniture needed to be added one bedroom floor was required to be more level before it was suitable to be registered. The home had made some improvements to the building since the last inspection. The reception hall had been decorated and a new non-slip wood effect floor had been added. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 14 The home had created a toilet area off the main lounge for residents and this will be useful for a number of residents. This toilet as the other new toilets in the home needed either grab rails or toilet frames to assist residents with physical disabilities. A number of aids and hoist remained in the main lounge and this does not give a homely feel to this area. The smoking lounge had been further improved since the last inspection by adding a feature fireplace. The manager of the home said that a previous requirement about putting right some water damage remained outstanding. Work to upgrade the decoration in some bedrooms required at the previous inspection was not inspected on this occasion. The home was clean and fresh in the areas of the building seen on this occasion. It was clear that the implementing procedures to ensure good infection control in laundry and had separated one resident’s clothing and linen as required. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 15 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): 27, 28, 29, 30 The home has a turn over of staff that affects their ability to ensure good recruitment and training practices. This means that for residents to get consistent care, care planning becomes much more important. The number of staff available was appropriate to provide the care. EVIDENCE: Three weeks rotas showed that the home routinely had three care staff on duty throughout the day and a manager. Ancillary staff were also available in the home. This currently meets the residents’ needs but a review of staffing will be required when the extra beds are agreed. The home had yet to meet the target of 50 of the care staff with NVQ2. Although the home had improved on their processes for recruitment the home must continue this in all instances and meet the requirements of the Criminal Records Bureau. The home did not have a systematic approach to training, they did not have matrix of achievement so did not have a tool for planning future training. Turn over of staff contributed to the problems of maintaining a well-trained staff group and the home need to explore other ways in which training can be delivered consistently. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 16 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, 33, 36, 38 The management staff of the home had reduced since the last inspection and this meant that important issues of staff supervision, the managers training needs and quality assurance had not been met. These are all important if the home provide a service suitable for their residents. EVIDENCE: The care manager has owned the home since 1992 and became the Registered Manager in 1998. She has yet to complete the Registered Managers award and the NVQ4 in care. The manager had a deputy that had training but she has recently moved on. This and other staff issues have left the home short of managers to complete the full range of management tasks needed. The home has no quality assurance systems and this increasingly this is a need to ensure that good care is maintained. Quality assurance systems ensure that any trends such as increased numbers of residents falling, having accidents, or issues of maintenance in the building are identified and dealt with promptly. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 17 The supervision of staff has not been undertaken consistently since the last inspection although this had been an area of improvement at the last inspection. Whilst a full audit of maintenance and inspection contracts was not undertaken the home had in place the required gas certificate after some work had been undertaken. An inspection carried out by the West Midlands Fire Service in December and a number of actions were required. A number of these remain outstanding and must be completed to the satisfaction of West Midlands Fire Service. The requirements made are repeated in this report. A number of requirements about the kitchen were not assessed on this occasion and were brought forward. Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 18 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 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 1 X 2 Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14 Requirement The home must ensure that all areas of the assessment outlined in standard 3 are commented upon in each resident’s assessment. Care plans must in all cases give clear instructions to staff as to how care is be given. This requirement remains outstanding since 05/09/05. Care plans must not be displayed on bedroom walls. This requirement remains outstanding since 15/08/05. Labels on wardrobes and chest of drawers must be removed. This requirement was not assessed on this occasion and was brought forward from 15/08/05. The home must develop an activities programme for service users of the home and keep a record. This requirement remains outstanding 31/05/05. Records must be kept of individual time spent with residents unable to join DS0000016738.V277437.R01.S.doc Timescale for action 31/01/06 2 OP7 15(1) 31/01/06 3 OP10 12(4)(a) 28/02/06 4 OP10 12(4)(a) 28/02/06 5 OP12 16(2)(n) 31/03/06 6 OP12 16(2)(n) 31/03/06 Barkat Version 5.1 Page 20 7 OP15 8 OP18 9 OP19 10 OP21 11 OP24 13 OP24 14 Barkat OP28 activities. This requirement remained outstanding since 31/08/05. 12(1)(a) The task of assisting residents to eat must be undertaken in an unhurried and sensitive manner. This requirement was not assessed on this occasion and was brought forward from31/07/05. 13(6) The Registered Manager must ensure that staff have the relevant training in adult protection. This requirement remains outstanding since 30/04/05. 23(2)(b) The Registered Manager must ensure that water damage evident in some areas is repaired This requirement remains outstanding 30/04/05. 23(2)(n) All toilets must have the provision of two grab rails or a toilet frame. This requirement remains outstanding 05/09/05. 23(2)(d) The Registered Manager must ensure that an audit of each bedroom against the standard is undertaken and ensure that the service users have access to all the required furnishings unless their risk assessment proves that this would be unsafe for service users. In this case this must be recorded in their care plan and subject to review. This requirement was not assessed and is brought forward from 01/07/04. 23(2)(c) The home must continue to refurbish bedroom areas to bring up to standard. This requirement was not assessed and is brought forward from 01/07/04. 18(1)(c, i) The home must have a plan to achieve 50 qualified NVQ2 DS0000016738.V277437.R01.S.doc 28/02/06 31/05/06 30/04/06 28/02/06 31/03/06 31/03/06 30/06/06 Page 21 Version 5.1 15 OP29 19(4) 16 OP30 19 2(4) 18(1)(c) 17 OP30 18(1)(c) 18 19 OP31 OP36 9 18(2) 20 OP33 24(1)(2) (3) 21 22 23 OP38 OP38 OP38 23(4)(c) 23(4)(c) 23(4)(c) 24 OP38 23(4)(c) staff by December 2005. This remained outstanding since 31/08/05. All new staff must have a CRB check any variation in this must be discussed with the inspector. This requirement was outstanding since 28/02/05. The Registered Manager must ensure that staff files: Have copies of the member of staffs relevant qualifications to demonstrate that staff have met the National Training Organisations targets. This requirement remains outstanding since 01/07/04. The home must ensure that all staff have regular update training to maintain their competence in core areas in a timely way and maintain a record of this. The registered manager must undertake the NVQ4 in care and the Registered Managers Award. Staff must receive regular routine 1 to 1 supervision. A rota of planned supervisions must be sent to the Commission The home must set up a method of quality assurance and this must be reflected in the homes business plan. This requirement remains outstanding since 01/07/04. The heat detector in one bedroom must be replaced by a smoke detector. Cold smoke seal must be replaced on a bedroom. An electro magnetic lock must be placed on the front door to ensure it is opened in case of fire. The basement must be cleared of combustible materials and the fire resistance of the area must DS0000016738.V277437.R01.S.doc 28/02/06 28/02/06 31/03/06 31/12/06 28/02/06 31/03/06 28/02/06 28/02/06 28/02/06 28/02/06 Barkat Version 5.1 Page 22 25 OP38 23(4)(c) 26 OP38 23(4)(c) 27 28 OP38 OP38 23(4)(c) 23(4)(c) 29 OP38 23(4)(c) 30 OP38 13(3) 31 OP38 13(3) 32 OP38 13(3) 33 OP38 18(1)(a) be improved as required by West Midlands Fire Service. The fire door from the kitchen into the main lounge must be made available at the same time must not increase risks to residents. The refurbished bedrooms on the first floor must only be given to residents that are mobile and this will be part of the conditions of registration when the rooms are completed and approved. Staff training on fire must be updated. The fire risk assessment must include details of the people with disabilities that place them at extra risk in case of fire and plans. A review date of this risk assessment must be specified. One clear action plan must be in place in case of fire and staff must have detailed knowledge of this plan. Cleaning staff must not walk through the kitchen. This requirement was not assessed and was brought forward from 31/07/05. Frozen meat must be appropriately wrapped and dated. This requirement was not assessed and was brought forward from 31/07/05. Seals on a freezer must be replaced. This requirement was not assessed and was brought forward from 31/07/05. To ensure the safety of residents the management of the home must be strengthened and a full time deputy, with care experience and qualifications, must be in place as a permanent addition. DS0000016738.V277437.R01.S.doc 28/02/06 28/02/06 28/02/06 28/02/06 28/02/06 28/02/06 28/02/03 28/02/05 31/03/06 Barkat Version 5.1 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 2 Refer to Standard OP3 OP9 Good Practice Recommendations It is recommended that the date of assessments are clearly recorded on an any assessment format. The medicine policy must include instructions as to what to do in the event of a drug administration error. The homely remedy policy must specifically medicines the home wishes to purchase. Protocols for when required medicines must be written which include indication, dose, time interval between doses, maximum daily dose, appropriate recording and review date. The prescribing doctor must sign these. The home must see the actual prescriptions prior to dispensing to check the dispensed medication and Medicine Administration Record (MAR) chart for accuracy. It is recommended that the home stores aids in a different area to the main lounge. 3 OP22 Barkat DS0000016738.V277437.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Barkat DS0000016738.V277437.R01.S.doc Version 5.1 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. 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!