Inspection on 26/08/05 for Barleycroft Care Home Ltd.

This inspection was carried out on 26th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Barleycroft Care Home Ltd. 18/03/09

Barleycroft Care Home Ltd. 18/04/07

Barleycroft Care Home Ltd. 20/12/06

Barleycroft Care Home Ltd. 02/06/06

Barleycroft Care Home Ltd. 11/05/05

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Barleycroft Care Home Ltd Spring Gardens Romford Essex RM7 9LD Lead Inspector Rhona Crosse Unannounced Inspection 26 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Barleycroft Care Home Ltd Address Spring Gardens, Romford, Essex RM7 9LD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 504 6565 Festival Care Homes Ltd Jennifer Martin CRH Care Home 80 Category(ies) of DE Dementia (50 years and over) registration, with number DE(E) Dementia - over 65 of places OP Old Age PD Physical Disability (50 years and over) PD(E) Physical Disability - over 65 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of beds 80 to be used flexibly amongst the various categories. With the following categories: Old age, not falling within any other category (OP) either sex Residents 50 years of age with a diagnosis of Dementia (DE) either sex Residents 65 years of age with a diagnosis of Dementia (DE)E either sex Residents 50 years of age with a Physical Disability (PD) either sex Residents 65 years of age with a Physical Disabilty PD(E) either sex One Resident 40 years of age Physical Disability (PD) Date of last inspection 11 May 2005 Brief Description of the Service: Barleycroft is a purpose built care home providing 24 hour nursing care to 80 service users. All accommodation is in single occupany rooms each with an ensuite. The home is arranged over three floors. There is a passenger lift to all floors.The home is situated near Romford and is on a good bus route to other local areas. Romford has a British Rail Station. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection so the home did not know the inspector was coming. The inspector arrived at 11.35am the manager was at the home and interviews for new staff were taking place. The home was appropriately staffed. The inspector looked at daily records, care plans, food and fluid charts and accident records. An inspection of a random selection of bedrooms, bathrooms and communal rooms was undertaken. A discussion with relatives visiting also took place. Due to the ongoing concerns about the operation of the home, this home will receive more than the two mandatory inspections that all homes have to have within the twelve month period (March 2005 – March 2006). Due to this inspection being a monitoring inspection to check compliance with the previous inspection due to concerns about the operation of the home no service users were spoken with during this inspection. What the service does well: In a discussion with a relative during the inspection the relative felt that the home were caring for her relative appropriately. Food was said to be of a good standard. Clothing was said to come back to her relative well laundered. The kitchen was clean and well organised. The cook had made a chocolate marble cake for the service users tea. The inspector was given a piece of the cake with a cup of afternoon tea. The cake was very well made being fluffy and moist, the cook was congratulated by the inspector as the cake was excellent. Pre admission information was available for inspection on each file along with the placing authorities care plan. Information was also available in relation to the needs and wishes of service user at the time of death. Service users bedroom were full of personal possessions, the home encourages service users to being personal possessions into the home to make their rooms more homely. This inspection looked at areas that were of concern to the Commission therefore other areas of ‘what the service does well’ were not inspected at this inspection. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Although the majority of care plans are being updated when changes occur, it was of concern to the inspector that some information in care plans picked by the inspector at random still did not hold all the information to ensure appropriate care is provided. Therefore this remains a concern for the Commission. After a fall a service user was given pain killers twice before it was observed that a fracture had occurred as a result of the fall. No pain killers should be administered after a fall as this masks the pain felt by the service user and could have serious consequences. Staff must to be trained to act appropriately after a service user has a fall. An inspection of staff employment records showed that the files picked by the inspector at random had missing information. For 4 staff there was no evidence that the home had applied for a CRB check (old CRB checks were found in the staff files that were provided by staff from other employers). CRB checks are not transportable therefore the home must apply for the checks to be carried out prior to staff working in the home. This is for the protection of vulnerable adults that they care for. It is recommended that the home keep a record of the reference number on each CRB check applied for and also the date it was sent for processing. Also of concern is that references provided for staff were not always taken up from the last employer. Although staff had 2 written references these were from colleagues working in the Barley Croft or colleagues from previous homes none of these were from the Human Resource departments of the previous homes, or line managers (apart from Mrs Martin in her previous role as their manager). As staff currently employed at Barley Croft are providing references for new staff this is creating a ‘closed’ community and is poor employment practice. This situation must be addressed by Festival Care. Complaints made to the home about the care of service users are either in the process of investigation or have been investigated. The home has failed to ensure the safety of service uses due to poor medication practices and poor Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 7 physical care. Ongoing adult protection investigations will be reported on when these are completed by the various agencies involved. Closer monitoring of service user’s in the lounge areas must take place to ensure their health and wellbeing. Medication practice will be fully inspected at further inspections. 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. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 standard 6 does not apply to this home as they do not provide this service. Standard 3 was met. EVIDENCE: From a random selection of service user’s files it was established that each service user had a written pre assessment held on file which was completed prior to them being admitted. There was also a care plan provided to the home by the placing authority also held on file. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 11 Greater care and monitoring is required to ensure that care plans are updated as changes occur. Closure monitoring of service user’s in the lounge areas must also take place to ensure their health and wellbeing. Standard 11 is well managed with information readily available. EVIDENCE: A random selection of care plans picked by the inspector found that the majority had been updated. However for one service user the care plan had not been updated for the month of July. For another service user whose care plan had been updated in part on return from hospital had gaps in the care planning. Also for the same service user a GP visit (on the 18/8/05) stated ‘if the service user vomits they must be sent immediately to hospital’ this was recorded in the GP visits record sheet. No changes to the service users care plan had been updated to reflect this serious concern. This is poor practice. A further service user had a weight loss but was not placed on a food monitoring chart after this weight loss, therefore the home could not evidence Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 11 if the service user had eaten enough during the period of weight loss. Other service users appeared to be having their food monitored when this was not always necessary. The food monitoring chart does not identify exactly what the service user has eaten. It stated varying degrees from a ½ to a full diet, which is then ringed. The home would have problems identifying exactly what had been provided should they be asked to identify this. The food chart should be changed to identify the specific meal provided and the quantity eaten at each meal time. For another service user who had a ‘turn’ chart being completed the turn chart identified that the service users was on their back and left on their back at each turn recorded (for two days the record identifies the turn as back, back and so on). On this record there are two dates recorded 08/05/05 then 1/08 is recorded outside the date and time column (it is unclear therefore which date this record refers to). Records must have only one date and run consecutively. For the turn charts for the 7/8/05 and 8/8/05 entries recorded of turns over these two days show only two entries where the person was placed on their left side. The care plan does not identify this person may turn onto their back nor did the daily records state this. However the record does not evidence that a turn from left side to back or right side to the back took place. The nursing records must be able to evidence the care provided to a service users at all times. For a further service user whose care plan was inspected it showed that the service user required a pain killer to be given prior to any dressings on pressure areas taking place. The pain killer had been changed and the service user was now getting pain relief via a ‘ medication patch’ and did therefore not require pain relief prior to any dressing being applied. The care plan was not updated to reflect this change in care. For this service user a nursing assessment review had been started but had not been completed. This document must be completed fully each time it is reviewed Information in relation to the needs and wishes at the time of death were documented on care plans. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 14 were not inspected. Standards 12 &15 were inspected at the last inspection therefore they were not re-inspected at this inspection. However all standards in this section will be inspected at further inspections. EVIDENCE: Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 These standards are not well managed. EVIDENCE: There have been several complaints raised with the home, the host Social Services department and the Commission since the home opened in January 2005. Currently one complaint has been referred to the Adult Protection Coordinator for Havering and the local Police. A complaint was investigated as part of this unannounced inspection. This complaint had been made to the Commission. The areas of concern were miss medication resulting in overmedication of the service user, poor personal hygiene and the service user being made to use an incontinence pad when the care plan stated that there was no incontinence, also the attitude of staff to the complainant and the previous home carer of the service user. The placing authorities care plan was completed on 15/7/05 and faxed over to the home on the day of admission 15/7/05. The homes manager stated that the fax machine had run out of ink and therefore the fax did not come through and was consequently not received by the home until 18/7/05. This is poor practice on the part of the home. All equipment must be in working order. The home should have queried why no care plan was received on the 15/7/05, if this had been done, other arrangements could have been made with the placing authority to get the information to the home on the day of admission. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 14 As to the miss administration of medication, the original writing on the medication administration record at the time of admission has been over written. The complainant saw the original document and stated that the manager had ‘corrected’ the medication administration sheet. Due to this over writing the inspector could not establish what the original document had recorded for the medication Quetiapine. Diazapam was to be administered as a ‘when necessary’ medication one 5mg tablet this was administered 4 times between 08.00 and 22.00 hours on the 16/7/05 as recorded on the medication administration sheet. The manager should have been aware that medication records must not be overwritten this is very poor practice. The home should have rewritten a new medication administration sheet with the correct information. However from examination of the medication administration sheet and daily records evidence that there was a miss management of medication. This part of the complaint is substantiated The manager stated on the 18/7/05 she had asked a staff member to make contact with the GP. The daily records show that it is not until the 20/7/05 that the GP visits in relation to the concerns around the medication making the service user lethargic. This part of the complaint is substantiated. Daily records evidence that the service user was in clothing from the previous day, with refusals to be cared for. Contact could have been made with either the complainant or the past carer who had left instructions that they would assist if there was any problem with the care of the service user at any time. The home did not act on this and left the service user in soiled clothing. This part of the complaint is substantiated. The care plan from the placing authority clearly states that the service user is not incontinent. It was admitted by the manager that the home put the service user in incontinence pads. This part of the complaint is substantiated. As to the attitude of the staff members to the complainant and the past carer, the home have met with the relatives to discuss all the concerns that were raised. The area manager is carrying out her own investigation and will inform the relatives and the Commission of the outcome on the completion of her investigation. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Standard 19, 24 and 26 are not well managed. This is due to the odour of stale urine in bedrooms and the beds being made up ready for re-use with soiled and stained linen. Some pillows were also unsuitable for use being lumpy and misshapen. EVIDENCE: Service users are encouraged to personalise their bedrooms and their was evidence of many personal possessions in the bedrooms. All rooms have call alarm systems and these were randomly checked. Staff responded to the alarms with a reasonable time period. Some bedrooms were filled with personal possessions and looked very homely. The en-suite of bedroom 28 had a leak in the soil pipe. At the time of inspection the manager said that this had not been repaired. After the inspection the manager provided a fax to say that the repair to the pipe had Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 16 been completed. However work needs to be carried out to repair the damage to the wall of the en-suite and disinfect the area the soil pipe leaked into. As the home is still under 1 year old the original building company would be responsible for attending to this fault and repair. The manager must ensure that this is completed quickly to the benefit of the service user. A random selection of bedrooms were inspected in the afternoon. Rooms had been cleaned and beds had been remade ready for re use that night. Whilst the majority of the bedrooms were clean and free from odours, bedrooms 28, 36, 57, 59 and 64 had strong odours of stale urine. Odour control must be improved. These rooms may require daily shampooing of the carpets or a different carpet cleaner needs to be used to remove the odours. One bedroom had had the carpet cleaned that morning and was free from odours. Bedding was checked at random. The inspector found beds made up ready for re-use with stained linen on them (none of these bedrooms had been used by service users after the beds were made as the majority of rooms were locked from the outside). Bedroom 28 had soiled linen, the pillow case, bottom sheet and duvet cover had staining on them. Bedroom 46 had a stained pillow case. Bedroom 50 had a stained duvet, pillow case and bottom sheet. Bedroom 67 had faeces stains on the bottom sheet and duvet. Pillows in bedrooms 36, 43, 46, 58 had pillows that were misshapen and unsuitable for use. These must be replaced. All linen must be free from stains and pillows must be suitable for use. Heating and lighting were not in use due to the time of year. Water temperature in bathrooms and en-suites was checked and on the day of inspection was in line with the temperature guidance. Infection control was poor in bedroom 53 as the protective covers for the bed rails had been placed next to the lavatory pan in the en-suite whilst not in use. This is poor practice. The home has adequate bathrooms, lavatories and shower facilities. All were found to be clean and free from odours. One assisted shower on the first floor was not working. This affects the service users and therefore the Commission should have been informed of this under Regulation 37 ‘significant events’. The home has aids and adaptations in bathrooms and lavatories. There is also a range of hoists to aid lifting and handling. Specialist beds and mattresses and cushions to aid pressure relief are provided to service users who require these for medical reasons. In one bathroom a large wheeled bin was stored. This held a lot of clinical waste and should not be stored in a bathroom. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 17 A smaller lidded bin suitable for the storage of clinical waste should be used (these smaller bins were observed in the sluice room). The large wheeled bin is used to transport clinical waste through the home to the outside storage area. Staff stated that the sluice rooms are too small to house such a large bin. The home must find a suitable place to store these large wheeled bins. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The standards 29 and 30 are poorly managed. Therefore vulnerable service users are not being protected. EVIDENCE: There is a good skill mix within the staff group as well as a mix of ages and a mix of male and female staff. Whilst there appears to be an appropriate number of staff hours allocated to the service users during the day, the allocation of duties that staff are to perform does not appear to be monitored. The lounge area was not being monitored by staff resulting in an accident that was avoidable happening. It is recommended that the home look at how the staff are delegated duties for the day and ensure that the lounge has a staff member who is located to be in the lounge to monitor the very dependent service users. A selection of staff employment files were picked at random by the inspector. It was observed that 4 staff did not have a current CRB check (criminal records bureau) applied for by the home. The manager stated that the staff members had had CRB’s sent off and were awaiting return of the disclosures, however the home could not evidence this at the time of the inspection. Staff should not commence duties without a CRB being taken up by the home. The home must ensure that they protect vulnerable service users. It is recommended that the Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 19 home keep a record of the reference number of the CRB form (these are different for each CRB document) along with the date the document was sent for processing. Although all staff had a written induction programme many of the staff who have been at the home since it opened (January 2005) did not have a completed induction programme. Many entries of staff induction programmes that were left blank were in relation to lifting and handling procedures. The manager stated that these had all been achieved, but had not been documented. These records must be appropriately completed after each part of the induction process has been achieved. The date and signature of both the person carrying out the induction and the staff member who has completed that part of the induction should be recorded. This must be addressed urgently as any formal action the home may need to take against a staff member may be compromised if the induction programme is incomplete. Further concern was raised with the manager in relation to the references taken up for staff. Although staff had 2 written references it was observed that some of the references were not from the last employer. The Care Homes Regulations state that one reference must be from the last employer. It would appear that several references were provided by staff currently working at the home for staff who were and have subsequently been employed by the home, with the current manager supplying some of these. The Human Resource department of one particular home could have been contacted for employment references for these staff members. The employment practice of the manager must be monitored by Festival Care to ensure that this situation does not arise again as this process creates a ‘closed’ environment where staff loyalty to each other may hamper the care and well being of vulnerable service users. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 and 37. Standards 35 and 38 will be inspected at further inspections. Standards 33, 36 and 37 are poorly managed. Staff who held onto information in relation to suspected abuse until the manager returned from annual leave placed vulnerable service users at risk. Festival Care have higher management structures to whom staff can report concerns too. EVIDENCE: The home cannot evidence that it is being run in the best interest of the service users due to the adult protection procedures that were not instigated as staff waited for the registered manager to return from annual leave before reporting an incident of alleged abuse. Whilst the manager was on annual leave a situation arose that has since resulted in the suspension of a member of staff and the commencement of adult protection procedures. This incident was not reported to anyone (no contact was made with relatives, the social worker for the service user or Adult Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 21 Protection Co-ordinator for the area) until the registered manager returned. This is poor practice and placed very vulnerable service users at further risk. Staff did not act in line with the homes policies and procedures. The home has appropriate support from the senior management structure within Festival Care and this should have been reported to the senior management team in the manager’s absence. The poor employment practices carried out by the manager are also of concern to the Commission. None of the staff employed have had any formal written supervision. All staff must have formal written supervision this must take place a minimum of 6 times in any one rolling year. This must be addressed with urgency as the home has been registered since January 2005. An accident that could have been prevented resulted in a service user suffering a fall from a wheelchair, the result of this fall was very extensive bruising. The service user had been brought back to the lounge area and had been left by staff unattended in a wheelchair. Whilst left unattended the person fell from the wheelchair and suffered extensive bruising. Service user’s should be monitored by staff in lounges and not left unattended. No service user should be left in a wheelchair that is only designed for transportation. The manager must ensure the safety and well being of service users at all times and ensure that they are not placed at unreasonable risk. The manager did not report to the Commission a ‘significant event’ as should take place under Regulation 37. There was a leak in the soil pipe in the ensuite of bedroom 28 and the shower unit in the first floor assisted shower room which is not working. The Commission must be informed of all significant events. The lack of reporting significant incidents was a requirement at the last inspection in May 2005. The Commission will take formal action of there are any further instances where non-reporting of significant events occur. The filing of documents in relation to service users care was found to be poor when an ‘overflow’ file for a particular service user was accessed. There were health documents for 4 other service users and photocopies of prescriptions found in the this file. Another document (weights of all service users) was also in the file. All records for all service user’s must be held securely and be in date order. The home must be able to provide documents for each service user’s care. These misplaced documents give cause for concern. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 3 3 2 3 1 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 x x 1 x x 1 1 x Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) & (2) Requirement Care plans must be updated as changes occur. This is an outstanding requirement from the last inspection. The previous timescale was 30/6/05. The home must be able to show a record of any nursing care provided. Turn charts must be appropriately completed Pain killers must not be given to service users after an accident prior to medical advice being sought as this masks the pain a service user may be experiencing. Repair the walls and redecorate the en-suite of bedroom 28 where the soil pipe was leaking. Repair the shower in the assisted shower room on the first floor Ensure bedding is fit for use at all times (stained linen and misshapen pillows must be replaced). Ensure that odour control is improved by daily cleaning of carpets in bedrooms where incontinence occurs. Ensure that CRB checks are Version 1.40 Timescale for action 30/12/05 2. OP8 17(1)(a) schedule 3 3 (k) 13(4)(c) 30/12/05 3. OP8 4. 5. 6. OP19 OP21 OP24 23(2)(b) 23(2)(b) 16(2)(c) 26/8/05 and ongoing action after any accident in the home. 30/10/05 30/10/05 26/8/05 and ongoing action. 1/9/05 and ongoing. For staff Page 24 7. OP26 16(2)(k) 8. OP29 19 1-8 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc taken up prior to staff commencing duties. 9. OP29 19 1-8 10. OP18 & 33 12(1)(a) & 13(6) 11. OP36 12(1)(a) 12. OP37 12(1)(a) 13. OP38 18(1)(c) (i) employed by 30/12/05 and ongoing as new staff are recruited. Appropriate refferences must be As new sought prior to employment. One staff are reference must be from the last recruited. employer. The second may be a character reference. The home must be run in the Ongoing action best interests of the service users. Service users must be protected from abuse at all times. Any suspected abuse must be reported immediately to senior management. (Staff must not wait for the registered manager to return from annual leave). All staff must have 6 formal To written supervision sessions commence within one rolling year. by 30/12/05 Records must be kept securely Ongoing held in files. (one file held action for several documents relating to 4 all records other service users. The home held for must be able to show continuity service of care from records held.) users. Staff must be appropriately 30/12/05 trained to deal with accidents.Written conformation that all staff have received this training must be forwarded to the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 25 No. 1. 2. 3. Refer to Standard OP27 Good Practice Recommendations Review the tasks set for staff throughout the day. The lounge where frail service users sit should be monitored at all times It is recommended that he home keeps the reference numbers of CRB checks applid for and the date they are sent for processing. It is recommended that closer monitoring of accident forms is undertaken. OP38 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 Barleycroft Care Home Ltd G55_S0000062659_Barleycroft_V245927_260805_Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!