Inspection on 19/01/06 for Barrow Hall Care Home

This inspection was carried out on 19th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 46 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Barrow Hall Care Home 21/10/08

Barrow Hall Care Home 22/10/07

Barrow Hall Care Home 26/09/06

Barrow Hall Care Home 25/07/05

Barrow Hall Care Home 17/02/05

Barrow Hall Care Home 23/08/04

Barrow Hall Care Home 27/02/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Barrow Hall Care Home Wold Road Barrow On Humber North Lincolnshire DN19 7DQ Lead Inspector Ms Matun Wawryk Unannounced Inspection 19th & 20 January 2006 10:30 th Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 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 Barrow Hall Care Home DS0000032128.V261281.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 Adults 18-65. 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. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Barrow Hall Care Home Address Wold Road Barrow On Humber North Lincolnshire DN19 7DQ 01469 531281 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) Guardian Care Homes Mr Patrick Michael Griffiths Care Home 37 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number disorder, excluding learning disability or of places dementia (37) Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service user must be admitted directly to the Lodge. Service users accommodated in the Lodge must have completed a period of assessment in the main building prior to being accommodated in the Lodge. Before any service user is accommodated in the Lodge, the approval of the service purchaser and the service users medical consultant must be obtained and recorded. Only 2 service users can be accommodated in the Lodge at any one time. There must be no granting of over night stays for additional service users. 2. 3. Date of last inspection 25th July 2005 Brief Description of the Service: Barrow Hall is a listed building and retains many of its period features. The home is set in pleasant grounds in the village of Barrow, providing easy access to local shops and facilities. The home provides nursing care for up to 37 service users with a mental health problem. The home provides a choice of single and shared accommodation. In addition service users have access to a range of communal facilities including a dining room, sitting room and recreational area. Twenty five beds are provided in the main building, a further ten beds are provided in an adjacent building known as The Mews. The Mews consists of ten apartments. Two of the apartments have a separate bedroom, sitting room, kitchen and bathroom. The other eight apartments have an adjoining bedroom, sitting area and small kitchenette. All have separate bathrooms with showers, wash hand basins and toilets. Storage and telephone points are provided in all ten apartments. Two of the apartments have been adapted to accommodate service users with physical disabilities. The remaining two beds are provided in a self contained house situated in the grounds of the home. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 19th & 20th of January 2006. The inspection took twelve hours to complete. To find out how the home was run and if the service users were happy with the care and support they received, the inspector spoke individually to five service users and left a number of comments cards for service users and their relatives to complete and return to the Commission for Social Care Inspection. The inspector also spent time talking to the deputy manager, two nurses and three support workers who were working in the home at the time of the inspection. Paperwork and records were also looked at to make sure the home was carrying out proper checks on staff before they started work and to ensure staff were trained to do their job safely. A tour of some parts of the home also took place. What the service does well: What has improved since the last inspection? The manager had ensured that some essential repair works to the building had been carried out. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 6 Redecoration to most of the bedrooms and communal areas in the main building was underway at the time of this inspection. Once completed service users will have a safer and more comfortable home to live in. A number of bathrooms and toilets had been refurbished and redecorated. This means service users have access to better services and facilities. 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. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Prospective service users have their needs assessed and are offered the opportunity to visit the home prior to admission to ensure the home is able meet the service users’ identified needs. EVIDENCE: The inspector examined individual plans for two service users. Records and discussions with staff showed these individuals had had their needs assessed prior to admission to the home. In discussion with the inspector both the service users confirmed they had visited the home before they moved in to sample the level of service and to meet other service users residing in the home. This means the home takes appropriate action to ensure an assessment is available prior to prospective service users moving into the home means and service users are offered the opportunity to visit and have overnight stays. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Service users do not have care plans and risk assessments that reflects their full range of needs and choices. Without this there is no assurance the service users health, personal and social care needs will be met. EVIDENCE: A random selection of four care plans and other associated records were examined. Completed care plans and risk assessments were in evidence in all the files examined. However some risk assessments and care plans lacked detailed guidance for staff on care delivery arrangements and records showed monitoring of some care plans and risk assessments had not been carried out on a monthly basis. For example: Records for one service user who suffered from diabetes identified weekly monitoring of blood and urine levels was needed. Records did not evidence that required checks, as set out in the care plan, had been carried out. The care plans and risk assessments for two service users identified both service users exhibited frequent episodes of challenging behaviour, resulting in Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 10 regular use of PRN medication. Records indicated nursing staff regularly discussed issues and concerns with a visiting psychiatrist. However risk assessments and care plans for the management of challenging behaviours, including the use of PRN medication, were very brief and did not provide staff with clear and explicit guidance. For example: triggers and detailed management strategies. Although records showed incidents of challenging behaviour were being recorded in the daily records there was no evidence to show incidents were being monitored and evaluated on a regular basis to ensure lessons can be leant and future interventions modified as appropriate. This is needed to ensure the welfare and safety of service users and staff and to ensure appropriate management strategies are in place. Examination of records identified two occasions where physical interventions had been used with two service users. Risk assessments and care plans supporting the use of physical interventions had not been developed. The registered person must ensure risk assessments and care plans are developed for use of physical interventions. Risk assessments and care plans must be agreed with the multi agency care team and must be subject to regular monitoring and review. Similarly this is needed to ensure the health, welfare and protection of both service users and staff and must now happen. Assessment of need and care planning processes concerning the personal development and social needs of service users did not adequately address these areas. For example, none of the files examined contained social needs assessments and individual support plans. Failure to complete appropriate assessments means there is no guarantee that the service users’ social and personal development needs are being identified and met. This is needed to ensure a more holistic approach to the care and support of service users and must now happen. Please also refer to comments detailed on page 15 of this report. At the last inspection it was noted that the home was using a standard, tick box assessment tool. The effectiveness of this was discussed with the manager, who advised that a review of the risk assessment tool was to be carried out. A new risk assessment tool has now been identified and the inspector was advised the tool should be fully implemented within the home by the end of February 2006. The proposed risk assessment tool is used by local health and local authority staff and should mean a more consistent and co-ordinated approach to the assessment of risk. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 The personal development, recreational and social needs of service users are not well catered for. Service users are encouraged to maintain family links and friendships. Daily routines in the home are flexible to meet individual needs. The meals provided in the home offer service users choice and a variety of foods. EVIDENCE: Since the last inspection the registered person had appointed an activity coordinate. However this individual had only recently taken up his position and had therefore not had an opportunity to assume the full range of duties and responsibilities required by the post. Examination of records and discussions with staff and service users identified the home was not providing service users with a structured programme of activities. Although service users and staff commented that activities on offer over the Christmas period had been well planned and coordinated. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 12 As previously indicated, there was no evidence to show social needs assessments had been completed and current care plans did not addresses the personal development and social/recreational needs of service users clearly and consistently. This is needed to ensure activity programmes are developed which reflect the individual needs, preferences, capacities and aspirations of service users. Four out of the five service users spoken to stated there was not enough to do and all the staff the inspector spoke to confirmed this. This matter was fully discussed with the deputy manager who reported that significant progress in these areas would be achieved once the activity coordinator is established in his post. The registered person must, on a regular basis, consult service users about the programme of activities on offer in the home. A plan of activities having regard to the needs of the service users must be provided and arrangements for activities must be developed. Staff responsible for developing and implementing activity programmes must be provided with relevant training. These matters remain outstanding from the previous inspection and must now happen. The home does not provide transport and staff and service users commented that access to facilities and amenities was restricted due to the geographical location of the home. This matter was discussed with the deputy manager, it was reported that the owners of the home did not plan to provide a mini-bus or other means of transport in the immediate future. It was reported that one staff member transported service users in his own car. It was not evident from records that a check had been carried out to ensure the staff member had the necessary insurance cover. The registered person must ensure where and if staff use their own cars to transport service users they have appropriate insurance cover and appropriate risk assessments must be completed. Interviews with service users confirmed choice of food was provided. Service users reported that if they did not like something on the menu they would be offered an alternative. The home provides service users with three meals a day and a light supper. Discussions with staff and service users highlighted that service users can access cold drinks at any time. Hot drinks are available at set times and on request. Records of resident meetings confirmed service users had been made aware of this. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Arrangements for meeting the health care needs of service users are generally satisfactory although some improvement in care planning is needed. Personal support is provided in a way which respects the service users right to privacy and dignity. EVIDENCE: The inspector case tracked four service users and this included speaking to five service users individually. All of the service users spoken to confirmed staff respected their privacy and dignity. All service users were registered with a GP. A record of routine eye tests, dental and chiropody checks had been maintained Service user weights were monitored and since the last inspection appropriate scales had been purchased for service users who were unable to weight bear. The mental health needs of service users was being monitored by regular consultations with a visiting psychiatrist. However there was no evidence to show all that annual health check and been sought and provided for all of the service users. The registered person should ensure annual health checks are requested. This is needed to ensure all the health care needs of service users are identified and met. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 14 Records showed guidance in care plans had not always been followed. As previously indicated, one service user suffered from diabetes, regular checks on blood and urine levels as identified in the care plan had not been carried out. Records also showed the service user had experienced problems with his legs requiring medical intervention and treatment. The service users’ care plan had not been revised to reflect this. The registered person must ensure nurses update care plans to reflect all areas of current health needs, where monitoring of a health need is indicated, this must happen. This is needed to ensure the health care needs of service users are met. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has a satisfactory complaints procedure and complainants can be assured their complaints will be acted upon. The arrangements for the management of adult protection matters must improve through the provision of further training and supporting guidance. EVIDENCE: A complaints and protection of vulnerable adults procedure was in place. In discussion with the inspector staff reported understanding of the procedures and knew whom to contact to make a complaint and or to raise concerns regarding adult protection issues. The inspector also spoke to five-service users; all commented that they knew who to report concerns or complaints too. Examination of a sample of staff training records evidenced that some staff had not had adult abuse training. The registered person must ensure all staff are provided with adult abuse training. This is needed to ensure staff are able to recognise adult protection issues and to ensure staff are fully aware of their responsibilities and reporting arrangements. Corporate policies and procedures were in place to deal with physical and verbal aggression by a service user and for the use of restraint. At the time of the inspection this was being reviewed. The registered person must ensure the revised procedure reflects Department of Health Guidance on the use of Physical Interventions. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 16 Examination of records and discussion with staff evidenced staff had used physical intervention with a small number of service users. Training records showed not all staff had received training in use of physical interventions. This matter was discussed with the manager who reported training was planned but was not able to confirm exact dates. The registered person must ensure all staff receive such training and/or any required up dates as a matter of priority. This is needed to ensure the health, welfare and safety of service users and staff and must happen. Training must reflect Department of Health Guidance. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 29 & 30 The inspector was not able to fully assess whether the home’s environment and facilities fully meet the relevant Regulations and National Minimum Standard because of ongoing redecoration and building works. Service users do not have the specialist equipment they need to maximise their independence. EVIDENCE: A partial tour of the home was completed. Since the last inspection the owners of the home had initiated a redecoration programme for the main house. A number of the communal areas and bedrooms had been redecorated, although some finishing off was still needed. New wash hand basins had been provided in some rooms. The inspector was advised that new bedroom furniture, carpets and curtains had been ordered. Once this work is fully completed service users will have a more comfortable and attractive home to live in. Several of the bathrooms and toilets had been refurbished and redecorated, thereby providing service users with better facilities and services. The laundry and service user kitchen had been refurbished and redecorated. Work to box in exposed pipes in the laundry was planned. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 18 At the last inspection it was identified that a number of units in the main kitchen were damaged and needed repair or replacement. Similarly a number of wall tiles were noted to be loose and the fly screen needed to be replaced. The inspector did not go into the kitchen on this occasion. The deputy manager confirmed no work had been undertaken in the main kitchen. This poses a potential health and safety risk and remedial action must now be taken. Records and discussion with staff showed one service user had been assessed to need a specialist chair and hoist. This had not been provided because of on going wrangles over funding responsibilities. In discussion with the inspector some staff reported they had refused to manually move and handle the service user because of health and safety concerns. This is clearly an unacceptable situation and places both the service user and staff and staff at risk. The need to ensure appropriate moving and handling equipment was fully discussed with the manager who reported that he would take immediate steps to try and resolve the issue. The manager was not able to confirm when appropriate seating will be provided. This is unacceptable given the service user physical needs. The registered person must ensure service user A has access to all the specialist equipment he has been assessed to need. In the event that this cannot be provided in a timely manner, a re-assessment of the individuals needs must be completed to ensure the home has the capacity to continue to meet all the service users care needs. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Service users’ safety is compromised by inconsistencies in recruitment practice resulting in them receiving care from some staff that have not been properly vetted. This potentially leaves service users who use the service at risk. This is compounded by inadequate supervision. EVIDENCE: An examination of a sample of three staff personnel records was completed. Criminal Records Bureau disclosure checks had been carried out for two of these staff. Two staff had commenced working subject to receipt of satisfactory CRB checks. POVA 1st checks had been sought, although records indicate these staff commenced employment before the outcome of this check was received. One worker had one written reference and one verbal one. The verbal reference had not been followed up with a written one. One member of staff had applied for and been successful in obtaining a different post within the home. Although referees had been identified, references had not been taken up. The registered person must ensure two written references are obtained before staff commence working in the home. Verbal references must be followed up with a written one. Where staff commence working in the home subject to a satisfactory CRB check, POVA 1st checks must carried out before a worker commences working in the home. This is needed to ensure the protection of service users and must now happen. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 20 The home had detailed guidance in place for induction, training, development and supervision. Examination of training records showed support workers had accessed very little mental health training. This is needed to ensure staff have the necessary skills and competencies to meet the changing needs of service users and those areas set out in the homes Statement of Purpose. The home had implemented a good NVQ training programme and a number of staff will achieve an NVQ within the next few weeks. This means the home is on target to achieve 50 of care workers with an NVQ. Records showed a number of staff were not up to date with all areas of mandatory training, for example, manual handling, health and safety and fire safety. The registered person must ensure all staff are provided with required training. This is needed to meet health and safety requirements and to ensure the health, welfare and safety of service users and must now happen. The home does not have a separate budget for training. Budgets are centrally managed. The inspector examined the induction records for one staff member who had commenced working in the home since the last inspection. Records did not evidence induction training had been provided to Skills for Care (formerly TOPPS) Standards. Structured induction training is needed to ensure staff posses the necessary basic skills and competencies to meet service user needs. The registered person must ensure staff are provided with induction training, which meets Skills for Care Standards. Training records showed annual appraisals were carried out, however these were not up to date for all staff. The registered person must ensure annual appraisals are completed, this is needed to ensure training plans and priorities reflect the training needs of the whole staff team. This remains an outstanding requirement from previous inspections and must now happen. Staff had not been provided with training as set out in National Minimum Standard 35.4. This remains an outstanding recommendation from previous inspections and should now happen. These matters were discussed with the manager and deputy manager. Both recognised improvements in respect of specific and specialist training was needed and the deputy manager provided the inspector with a copy of a teaching programme she intended to deliver with care and ancillary staff. A programme of formal supervision was in place. However examination of a sample of staff supervision records showed this was not happening as often as Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 21 required by the Care Homes Regulations. This remains an outstanding requirement from previous inspections and must now happen. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 & 42 A qualified and experienced manager runs the home. However some systems, which support effective management of staff and operations had not been fully implemented in the home. EVIDENCE: The manager is a qualified nurse (mental health) and has completed a recognised management course. In discussion with the inspector all the service users commented on the friendliness and approachability of the manager. Some systems needed to ensure effective overall management of the service had not fully developed in the home for example, staff supervision, development, inconsistent recruitment practice and records. These matters were again discussed with the manager who gave an assurance that these issues would be addressed as a matter of priority. There were comprehensive health and safety policies in place and a health and safety statement. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 23 Some records had been stored because of the redecoration of a storage area and were therefore not available for inspection, this included the fire risk assessment, records of fire drills, fire alarm tests and equipment checks. The inspector was advised that the fire officer had carried out an inspection of the premises in December 2005. A report had not been received by the home, although the manager confirmed the fire officer had recommended some work. The registered person must confirm in writing that required checks have been carried out on the homes fire systems and that the fire risk assessment is current. Where necessary and required remedial work must be completed. Checks on water temperatures had not been carried between October 2005 and 16th January 2006. It was reported this was due to ongoing plumbing works. The inspector checked a sample of water outlets, water temperatures varied. The inspector advises that a check is made on water outlets to ensure temperatures are maintained at the required levels. The manager reported that a check had been carried out on the homes electrical wiring system. A report was not available. The registered person must confirm any required works have been completed or provides dates when work (where applicable) will be completed. Portable appliance testing (PAT) is over due. The manager reported that a contact has been set up with an independent company to carry out these checks. The registered person must ensure appliances are re-tested to ensure, as far as practicable these remain safe to use. The manager reported that a maintenance check had been carried out on the homes nurse call system. A copy of the report was not available. The manager reported the system was safe and in good working order. The environmental health officer had recently visited the home. A report was not available for examination. The manager reported only one recommendation was made concerning calibration of the food probe. The registered person must guidance issued by the environmental health officer is addressed. Safe working practices were maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid, COSHH and fire safety; gaps were noted on the provision of some mandatory training and this must now be addressed as a matter of priority. This is needed to ensure the health, welfare and safety of both staff and service users. Individual service user risk assessments were completed. However in some cases records were brief and did not provide sufficient guidance for staff on the management of challenging behaviours. Risk assessments had not been completed for the use of physical interventions and some staff had not been provided with training in the use of challenging behaviours and use of physical Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 24 intervention. This must now happen. Please refer to comments detailed on pages 12 &19 of this report. One service user had significant moving and handling needs. A professional assessment had been completed and a need for provision of a hoist and specialist seating had been identified. This had not been provided. Failure to provide such equipment places both the service user and staff at risk. Please refer to comments detailed on page 21 of this report. The registered person must ensure where service users have been assessed to need specialist equipment this is provided. Alternatively a re-assessment of the care needs of the service user must be carried out to ensure the home is able meet the assessed needs of the individual. Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 2 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 X X 3 2 X X X 1 x Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 26 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 YA36 Regulation 18 Requirement Timescale for action 31/03/06 2 YA8 16 3 YA26 16 The registered person must ensure supervisions are carried out and recorded at least six times a year. (Timecale of 31.7.04 and 31.8.05 not met) 31/03/06 Systems must be developed which will enable service users to contribute to the development and review of polices and procedures and mechanisms, which will enable service user participation in the dayto-day management of the home. (Timescale of 31.8.04 and 31.12.05 not met) The registered person 28/02/06 must provide service users with facilities as detailed in NMS 26.2. Where facilities are not provided on health and safety grounds, this must be documented. Service users must be DS0000032128.V261281.R01.S.doc Version 5.1 Page 27 Barrow Hall Care Home 4 YA32 18 5 YA42YA32 18(1)c ,12(4)b 6 YA12YA11 16 7 YA35 18 8 YA39 24(1)a&b,(2)(3) provided with keys to their rooms. Where access to a key is restricted risk assessments must be carried out. (Timescale of 31.7.04 and 31.11.05 not met) The registered person must develop and implement a training programme, which includes specific mental health training. (Timescale of 31.12.04 and 31.8.05 not met) The registered person must ensure all staff have had updates in all areas of mandatory training. (Timescale of 30.6.05 and 31.8.05 not met) The registered person must continue, on a regular basis, to consult service users about the programme of activities. A plan of activities having regard to the needs of the service users must be provided and arrangements for activities must be further developed. Staff responsible for developing and implementing activity programmes must be provided with relevant training. (Timescale of 31.9.05 not met) The registered person must ensure staff are provided with an annual appraisal. (Timescale of 31.10.05 not met) The registered person 31/03/06 28/02/06 31/03/06 31/03/06 31/05/06 Page 28 Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 9 YA43YA36 18 10 YA34 19. Schedule 2 11 YA27 23 12 YA26YA24 23 13 YA42YA24 13(4)a,23(2)o must provide an annual development plan for Barrow Hall based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. (Timescale of 28.2.06 not met) The registered person must ensure the registered manager is provided with regular formal recorded supervision and an annual appraisal. Timescale of 31.10.05 not met) The registered person must ensure two satisfactory written references are obtained prior to workers commencing employment. Missing references for worker A must be obtained. Verbal refernces must be followed up with a written one.Enhanced CRB checks must be obtained before workers commence employment. The registered person must reburbish the staff toilet next to the office. Timescale of 31.9.05 not met) The registered person must have all the service user bedrooms in the main home redecorated. Dirty and stained carpets must be cleaned or replaced. (Timescale of 31.10.05 not met) The registered person must have the damaged 28/02/06 16/01/06 28/02/06 28/02/06 28/02/06 Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 29 14 YA23YA9 13 & 15 15 YA6YA9YA23 13 16 YA23YA9YA6 13(6) units in the main kitchen repaired or replaced. Damaged tiles must be made safe or be replaced. (Timescale of 31.9.05 not met) The registered person must ensure where service users exhibit challenging behaviours, a detailed behaviour management plan(s) is be developed. These must be subject to regular review and monitoring. The registered person must devise and implement a system in the establishment whereby the recorded episodes of restraint and challenging behaviour are reviewed in a way that supports a review of each episode with a view to informing best practice in such circumstances and modification of the intervention plan as needed. The registered person must ensure risk assessments and intervention plans are in place to support the use of physical interventions. Intervention plans must describe the specific intervention that could be used. Risk assessments and care plans must be agreed with the service user or their repesentatives and the multi-agency care team. The registered DS0000032128.V261281.R01.S.doc 23/02/06 23/02/06 23/02/06 Barrow Hall Care Home Version 5.1 Page 30 17 YA6 15 18 YA6 15 19 YA12YA11YA6 15 &16 20 YA42 13 21 YA19 13(1) 22 YA19 13 person must confirm in writing that agreed risk assessments and physical interventions plans are in place for the two service users discussed with the manager at the inspection feedback session. The registered person must ensure care plans address all the service users identified needs. Plans must be subject to monthly monitoring or at agreed frequencies. The registered person must individual care plans are reviewed with the service user (involving significant others) at least six monthly and updated to reflect changing needs. The registered person must ensure assessments are completed covering the personal, social and recreational needs of service users. Individual support plans must be developed. The registered person must ensure where staff use their own cars to transport service users, staff must have appropriate insurance cover. Risk assessments must be completed. The registered person must ensure (with the agreement of the service user) annual health checks are requested The registered person DS0000032128.V261281.R01.S.doc 16/01/06 31/05/06 31/03/06 28/02/06 31/03/06 16/01/06 Page 31 Barrow Hall Care Home Version 5.1 23 YA23 13 & 18 24 YA32YA42 13(6)(7), 18(1)c(i) 25 YA23 13(6)(7), 18(1)c(i) 26 YA29YA42 13 must ensure where care plans determine specific monitoring of urine and blood this is carried out. Nurses must be reminded of their responsibilities in this area. A check must be made on service user C records to ensure staff are carrying out required checks. The registered person must ensure staff are provided with adult abuse training. The registered person must ensure staff are provided with challenging behaviour training including use of physical intervention. Training must reflect relevant Codes of Practice and Department of Health Guidance. The registered person must review the homes policies and procedures for challenging behaviours and use of physical intervention The policies and procedures must reflect current legislation and case law as well as government guidance and professional codes of practice. The registered person must ensure a hoist and specialist chair is provided for service user B. In the event that this cannot be provided a reassessment of this individual must be carried out to ensure the DS0000032128.V261281.R01.S.doc 31/03/06 28/02/06 28/02/06 25/01/06 Barrow Hall Care Home Version 5.1 Page 32 27 YA32 18 28 YA43 26 29 YA24 13 30 31 YA42 YA42 13 13 32 YA42 13, 23 home is able to meet the service users’ care needs. The registered person must ensure new staff are provided with an induction, which meets Skills for Care Standards. The responsible individual for the home must produce and make available a report under Regulation 26 of the Care Homes Regulations. The registered person must ensure the fire door near to room 10 is repaired. The register person must ensure the food probe is calibrated. The registered person must audit all water temperatures at outlets accessed by service users and ensure they are close to and not higher than 43°C. The registered person must ensure portable appliance testing is carried out 28/02/06 28/02/05 28/02/06 16/01/06 23/02/06 23/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA35 YA32 YA24 Good Practice Recommendations The registered person should staff are provided with training as detailed in NMS 35. The registered person must ensure that 50 of care staff achieve an NVQ. The registered person should carry out an assessment of DS0000032128.V261281.R01.S.doc Version 5.1 Page 33 Barrow Hall Care Home 4 YA42 the premises under the Disability Discrimination Act 1995 Part 3. The registered person should replace the fly screen in the main kitchen Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 34 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Barrow Hall Care Home DS0000032128.V261281.R01.S.doc Version 5.1 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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