Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 25/07/05 for Barrow Hall Care Home

Also see our care home review for Barrow Hall Care Home for more information

This inspection was carried out on 25th July 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users spoken to stated that the staff respected their privacy and dignity. Staff were described as friendly and approachable. Service users and staff reported that relatives are made to feel welcome when visiting the home, thereby helping service users to maintain family contacts. Prospective service users are offered the opportunity to visit the home and to have overnights stays prior to admission to meet other service users, staff and to sample the atmosphere and level of service provided by the home. Service users living in The Mews are provided with apartments that are nicely furnished and personalised to their own taste, thereby providing them with a private area to their liking where they can spend private time or receive visitors. There was evidence of good working relationships with social services and health staff.

What has improved since the last inspection?

The manager had provided different door locks for The Mews apartments to improve security arrangements for those service users living in them. The manager had ensured that some essential repair works to the building had been carried out. The majority of staff had been provided with adult abuse training to ensure staff understood how to recognise possible abuse and to ensure staff understood who to report concerns too.

What the care home could do better:

To make sure the home is safe and comfortable for service users to live in, redecoration to most areas of the main building must be carried out. Most of the bedrooms in the main house require redecoration as does the service user kitchen, and the laundry. Essential works to bathrooms and toilets must also be carried out. Activities in the home need to be better organised. Proper checks must be carried out on all staff before they start work to ensure the protection of service users. Staff must be provided with better training and supervision to ensure they know how to care for service users properly and to ensure service users are protected from staff that may not know how to do things in the right way. A quality monitoring system must be introduced to make sure that everyone is consulted about the running of the home and to ensure on-going improvements are made.

CARE HOME ADULTS 18-65 Barrow Hall Care Home Wold Road Barrow on Humber North Lincs DN19 7DQ Lead Inspector Matun Wawryk Unannounced 25th July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Barrow Hall Care Home Address Wold Road, Barrow On Humber, North Lincs, DN19 7DQ 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) 01469 531281 Guardian Care homes Mr Patrick Michael Griffiths Care Home 37 Category(ies) of DE(E) (2), MD (37) registration, with number of places Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 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 complete a period of assessment in the main building prior to being accommodated in the Lodge. 2. 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. 3. 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. 4. The registered person will appoint a person(s) to engage and support service users with leisure and recreational activities. Date of last inspection 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 ajacent 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 J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 25th of July 2005. The inspection took nine and a half hours to complete. To find out how the home was run the inspector spent time talking to the manager, the deputy manager, a nurse, two cooks 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. In addition the inspector spoke to five service users and received seven completed service user comment cards. What the service does well: Service users spoken to stated that the staff respected their privacy and dignity. Staff were described as friendly and approachable. Service users and staff reported that relatives are made to feel welcome when visiting the home, thereby helping service users to maintain family contacts. Prospective service users are offered the opportunity to visit the home and to have overnights stays prior to admission to meet other service users, staff and to sample the atmosphere and level of service provided by the home. Service users living in The Mews are provided with apartments that are nicely furnished and personalised to their own taste, thereby providing them with a private area to their liking where they can spend private time or receive visitors. There was evidence of good working relationships with social services and health staff. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 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 standard(s) 2 & 4 Prospective service users have their needs assessed and are offered the opportunity to visit the home prior to admission. EVIDENCE: The inspector examined the care records of two service users admitted to the home since the last inspection. Records showed these individuals had had their needs assessed prior to admission. In discussion with the inspector both these service users stated that they had visited the home on more than one occasion before they moved in. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 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 standard(s) 6, 7, 8 & 9 Service users had a service user plan that reflects the majority of their needs. However service users need to consulted more about aspects of life in the home. EVIDENCE: The inspector case tracked four service users. This included examining records relevant to these individuals and discussing their care needs with staff. The inspector spoke individually to two of the four service users selected for case tracking. The plans were detailed and records showed these were being monitored on a regular basis. Completed risk assessments were in place for each of the service users selected for case tracking and these had also been subject to regular review. The staff used a standard format for recording risks. The inspector discussed the effectiveness of this format with the manager, who advised that a review of the risk assessment format was to be carried out to try and identify alternative possibly more effective models. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 10 It was evident from discussions with service users and staff that some service users were assisted to manage their personal allowances. In addition staff made purchases on behalf of some service users. For example the home was block purchasing toiletries and cigarettes for some service users. Care plans supporting staff’s involvement in this area were not in place. This is needed to ensure the protection of service users and staff and to ensure the home can demonstrate how individual choices have been made. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 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 standard(s) 11, 13, 16 & 17 The recreational and social needs of service users are not well catered for. The meals provided in the home offer service user choice and a variety of foods. EVIDENCE: On registering The Mews a Condition of Registration was applied requiring the owner to appoint a person with specific responsibility for organising activities in the home. An activity coordinator was appointed, but has now left the home. Records and discussions with staff and service users highlighted that there was not a structured programme of activities on offer in the home. This is needed to ensure service users have their social and recreational needs met. The registered person must continue, on a regular basis, to 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 further developed. Staff responsible for developing and implementing activity programmes should be provided with relevant training. The home does not provide transport and staff and service Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 12 users commented that access to facilities and amenities was restricted due to the geographical location of the home. 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. A service user kitchen is available and some service users purchase their own tea and coffee. This means some service users have access to hot drinks at any time. However for those service users who choose not to purchase their own tea and coffee or do not have the resources to do this, access to a hot drink is potentially restricted. One staff member reported that some service users sold dinks to other service users. The inspector advises a review of the current arrangements for providing hot drinks. Hot drinks should be available at any reasonable time unless risks assessments and or medical advice or issues preclude this. Five staff members spoken to commented that the owners of the home had recently reduced the amount of money allocated to purchase food. Staff reported that the reduction in the budget meant that they were no longer able to purchase some foods previously available to service users. Staff stated menus would need to be changed because there were insufficient funds to purchase some items of food. Staff commented that they were now required to purchase cheaper and in some cases inferior products. This matter was discussed with the manager who confirmed that a revised food budget had been introduced. The inspector advises that an impact analysis is carried out to ensure service users are provided with a balanced, nutritional diet that where possible reflects the preferences and choices of all service users living in the home. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 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 standard(s) 18, 19 & 20 Arrangement’s for meeting the health care needs of service users is generally satisfactory and support is provided in such a way, which respects the service users right to privacy and dignity. However the arrangements for recording administration of medication must be improved. EVIDENCE: The inspector case tracked four service users and this included speaking to five service users individually. All the service user spoken to and those who completed a comment card reported that staff respected their privacy and dignity. All service users were registered with a GP. Records of routine health checks were maintained and service users mental health was being monitored. Most service users had their weight monitored on a routine basis. However the home did not have sit on scales. Because of this one service user, who is unable to stand and requires artificial feeding was not having his weight monitored routinely. Qualified nurses administer medication. Examination of a sample of service users medication administration records highlighted that nurses had failed to record administration of some medication to service users. This potentially places service user at risk. This matter was discussed with the manager who reported he would take immediate steps to try and address the problem. Changes to the way nursing homes can dispose of unwanted or unused medication means the home now needs to set up a contact for this. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 14 Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 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 standard(s) 22 & 23 The arrangements for handling complaints and allegations of alleged or suspected of abuse are satisfactory. EVIDENCE: A detailed complaints and protection of vulnerable adults procedure was in place. In discussion with the inspector staff reported understanding of the procedures and knew who to contact to make a complaint and or to raise concerns regarding alleged or suspected allegations of abuse. The inspector spoke to five-service users; all commented that they knew who to report concerns or complaints too. Since the last inspection one protection of vulnerable adult referral had been made. This matter was investigated and was found to be unsubstantiated Prior to carrying out the inspection the Commission for Social Care Inspection received a complaint. The complainant alleged that service users were being denied access to their monies and drinks. The complainant also raised concerns about the manner and attitude of a particular staff member. This complaint was looked into as part of this inspection of the home. No evidence was found to prove the allegations concerning the approach of a particular staff member and withholding of monies from service users. However a requirement has been set in the report requiring the manager to develop care plans for assisting service users to manage their personal finances, where applicable. The concern regarding restricted access to dinks was partially substantiated and a requirement has been made to review the arrangements for providing hot drinks. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 16 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 standard(s) 24, 27 & 30 The standard of the décor within the home does not provide service users with an attractive and homely place to live in. EVIDENCE: A tour of the home showed a number of areas required attention. This matter was highlighted in previous inspection reports. There was no evidence that the owners of the home had carried out work to improve the overall environment in the main home. This means service users are not provided with safe and comfortable surroundings. In particular: • • Most of the bedrooms needed redecoration. Cracks in walls and ceilings were noted. Wallpaper in most rooms seen was marked or stained. Some carpets needed cleaning or replacing. The service user kitchen was in a poor state. The floor covering was marked and stained. Kitchen cupboards were damaged, ceiling tiles were missing or broken, similarly wall tiles were also marked, dirty or damaged. J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 17 Barrow Hall Care Home • • • • The upstairs bathing and toilet block was in a poor state of repair. One shower was not working. A bathroom was also not working. Some wall tiles were dirty, stained and damaged. The bathroom in room 11 was closed off because of leaking valves, similarly the toilet basin in room 11a was broken and the bath panel in room 9 was damaged. Corridors in the main home needed redecorating. Several areas had bare plasterwork showing, cracks in some walls and ceiling were noted. The cloths dryers were broken and had not been repaired or replaced. Some units in the main kitchen were damaged. Wall tiles appeared loose. Staff reported that they were reluctant to try and clean the tiles because of fear they would fall off. This poses a potential health and safety risk. The fly screen was dirty and broken in places and the inspector recommends that it is repaired or replaced. Kitchen staff advised the inspector that the hot food cupboard sometimes did not get up to the required temperature. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 36 Some inconsistencies in recruitment practice were noted resulting in service users 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 and training of staff. EVIDENCE: An examination of a sample of five staff personnel records identified that Criminal Records Bureau disclosure checks had been carried out for these staff. However it was also noted that two workers only had one written reference and one worker only had one verbal reference. The manager was informed that missing references must be obtained and was also advised to ensure in future that all necessary employment records were obtained before workers commence employment. 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 required by the Care Homes Regulations. Training records showed annual appraisals were carried out. However from the sample of records looked at it was evident these were not up to date for all staff. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 19 Examination of training records showed support workers had accessed very little mental health training. From the records seen the inspector was not able to confirm staff were up to date with all areas of mandatory training. The manager was advised to confirm to the inspector what mandatory training had been provided. Failure to provide staff with mandatory and more specific training means staff may potentially not have the necessary skills and competencies to meet the changing needs of service users. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 & 39 A qualified and experienced manager runs the home. However some systems, which support effective management of staff and operations were not fully implemented in the home. A structured quality monitoring system was not in place. This is needed to make sure that everyone is consulted about the running of the home and to ensure continuous improvements are made. 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 were not fully developed in the home for example staff supervision, training and inconsistent recruitment practice. These matters were discussed with the manager who Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 21 gave an assurance to the inspector that these issues would be looked at as a matter of priority. From interviews with the manager, staff and service users it was evident that a system of regular reviews of aspects of the homes performance through a structured programme of self-review and consultations, which includes the views of service users, staff, relatives and relevant others was not in place. Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x 1 x x 1 Standard No 11 12 13 14 15 16 17 2 x 2 x 3 x 2 Standard No 31 32 33 34 35 36 Score x x 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Barrow Hall Care Home Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 2 1 x x x x J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 23 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 36 Regulation 18(2) Requirement Timescale for action 31.8.05 2. 8 16 (2)(c )23(2) (1)13(4) 3. 26 16 (2)(c )23(2) (1)13(4) 4. 35 YA32. The registered person must ensure supervisions are carried out and recorded at least six times a year. (Timecale of 31.7.04 not met) Systems must be developed 31.12.05 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 day-to-day management of the home. (Timescale of 31.8.04 not met The registered person must 31.11.05 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. Services users must be provided with keys to their rooms. Where access to a key is restricted risk assessments must be carried out. (Timescale of 31.7.04 not met) The registered person must 31.8.05 develop a training programme, which includes specific mental health training. Staffs’ identified training needs must be linked to Version 1.30 Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Page 24 5. 35 13 (2) 6. 32 13 ( C ) 7. 35 & 42 18(1)(c ) 12(4)(b 8. 27 & 42 23(2) (j) 9. 28 & 24 13(4)(a)2 3(2)(o) 10. 30 & 42 23(2)(o) 11. 6&7 12 & 15 12. 11 16 (m)(n) the homes annual training plan. (Timescale of 31.12.04 not met) The registered person must ensure staff are provided with training as detailed in NMS 35. (Timescale of 31.7.04 not met) The registered person must ensure that 50 of care staff achieve an NVQ by 31.12.05 2005 The registered person must confirm all staff have had updates in all areas of mandatory training. Where necessary staff must be provided with this training. (Timescale of 30.6.05 not met) The registered person must provide a detailed programme of works for toilets and bathrooms with timescales. (Timescale of 30.9.04 not met Superceded. See reg 24, 25, 26,27, 28, 29 & 30 The registered person must provide a detailed programme of works and replacement of furnishings for communal areas with timescales. (Timescale of 30.9.04 not met. Superceded. See reg 30, 31 & 35 The responsible person must provide a programme of works for the laundry, service users kitchenette and main kitchen with timescales. (Timescale of 30.9.04 not met Superceded. See reg 30, 31 & 35 The registered person must develop individual financial plans for service users who are assisted to manage their personal finances. (Timescale of 31.4.05 not met) The registered person must continue, on a regular basis, to consult service users about the programme of activities. A plan 31.12.05 31.12.05 31.8.05 25.07.05 N25.07.05 25.07.05 30.9.05 31.9.05 Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 25 13. 40 & 42 12 & 13 14. 20 19(1)(a)1 9(5)(a)17 (2) 18.(1c ) 24(1)(a)( b)(2)(3) 15. 16. 35 39 17. 35 & 36 18(2) 18. 34 19. Schedule 2 19. 17 16(i) 20. 19 & 42 13 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. The registered person must confirm that a procedure has been developed for wheelchairs and/or develop one. (Timescale of 31.4.05 not met) The registered person must ensure that the medication adminstration records are maintained accurately. The registered person must ensure staff are provided with an annual appraisal The registered person must provide an annual development plan for Barrow Hall based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. The registered person must ensure the registetred manager is provided with regular formal recorded supervision and an annual appraisal The registered person must ensure two written references are obtained prior to workers commencing employment. Missing refernces must be obtained The registered person must ensure service users are provided with hot drinks at such times as may reasonably be required unless the outcomes of risk assessments or medical advice/ conditions dictate otherwise The registered person must obtain sit on scales or make alternative arragement for 30.9.05 with immediate effect 31.10.05 28.2.06 31.10.05 with immediate effect. 31.8.05 with immediate effect 31.9.05 Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 26 21. 17 16(i) 22. 42 & 17 16(g) 23. 20 13 24. 27 23(2) (j) 25. 27 23(2) (j) 26. 27. 27 27 23(2) (j) 23(2) (j) 28. 29. 30. 31. 27 27 27 24 & 30 23(2) (j) 23(2) (j) 23(2) (j) 13(4)(a)2 3(2)(o) service users who are unable to staff to ensure weight can be routinely monitored The registered person must carryout an impact analysis of the new food budget. Service users must be provided with a varied, balanced and nutritional diet that where possible reflects the preferences and choices of all service users living in the home. The registered person must have the hot lock checked. Where necessary repairs must be carried out. The registered person must set up a contract for the dispoal of unsued and/or unwanted medication The registered person must ensure the upstairs bath is repaired or replaced. The bathroom must be decorated. The registered person must have the upstairs shower repaired or replaced. The shower room must be decorated. Damaged wall tiles must be replaced The registered person must reburbish the staff toilet next to the office The registered person must have the broken/damaged toilet in the upstairs bathroom block repaired. The registered person must have the toilet in Room 11a repaired or replaced The registered person must have the gents toilet downstairs redecorated The registered person must have the bath in room 11 repaired or replaced All communan areas of the home must be redecorated, including corriddors. Excluding the blue 31.8.05 31.8.05 31.8.05 31.9.05 31.9.05 31.9.05 31.9.05 31.9.05 31.9.05 31.9.05 31.10.05 Barrow Hall Care Home J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 27 32. 24, 42 23(2)(o) 33. 24, 26 23(2)(o) 34. 24, 42 13(4)(a)2 3(2)(o) 35. 24, 26, 28 13(4)(a)2 3(2)(o) 36. 24, 30, 42 13(4)(a)2 3(2)(o) room, the dinning room and main siting room. The resistered person must have the service user kitchen redcorated. Ceiling tiles, wall tiles must be repaired or replaced. The floor covering should be replaced The registered person must have all the service user bedrooms in the main home redecorated. Dirty and stained carpets must be cleaned or replaced The registered person must have the damaged units in the main kitchen repaired or replaced. Damaged tiles must be made safe or be replaced THe registered person must investigate potential damp paches and holes in plasterwork located in various parts of the home. Necessary repair work and redecoration of affected areas must be carried out. The registered person must redecorate the laundry, the floor covering should be replaced. Holes in plaster work must be repaired. Damaged and missing tiles must be repaired or replaced 31.10.05 31.10.05 31.9.05 31.10.05 31.9.05 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 24 42 Good Practice Recommendations The registered person should carry out an assessment of the premises under the Disability Discrimination Act 1995 Part 3. The registered person should replace the fly screen in the main kitchen J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 28 Barrow Hall Care Home Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire 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 J54_s32128_Barrow Hall_v231851_250705_Stage 4.doc Version 1.30 Page 29 - 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!