Inspection on 26/09/06 for Barrow Hall Care Home

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 14 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 19/01/06

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 HILARY SLIGHTS & MATUN WAWRYK. Unannounced Inspection 26 September 2006 09:00 th Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 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.V308604.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V308604.R01.S.doc Version 5.2 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.V308604.R01.S.doc Version 5.2 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. The registered person will appoint a person(s) To engage and support service users with leisure and recreational activities. 19th January 2006 2. 3. 4. 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. Barrow Hall nursing care for up to 37 service users with a mental health problem. A choice of single and shared accommodation is available. In addition service users have access to a range of communal facilities including a dining room, sitting room and recreational area. Twentyfive 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.V308604.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection of 2006/2007.The inspection visit was carried out on the 26th September 2006. Hilary Slights and Matun Wawryk Regulation Inspectors carried out the site visit, which took 9 hours to complete. The inspection commenced by the sending out a pre-inspection questionnaire to the home in July 2006. Questionnaires were also sent to service users and staff at the home. In addition a number of surveys were also sent out to relatives and health care professionals involved in the care. The questionnaires returned were as follows; nineteen service users, three visitors/relatives, six health care professionals and ten staff. Information received by the Commission in the past year was also used in forming the judgement regarding the standards of care within the home. During the visit the inspector spoke to the manager, five members of staff to find out how the home was run and six service users to find out if they were satisfied with the care support and facilities they were provided. The inspectors looked at records including service users care plans, staff training and recruitment, and other records in relation to the running of the home. The inspector looked around the home. What the service does well: Prospective service users are given the opportunity to visit the home and to be allowed to stay overnight to meet other service users and staff before they were admitted to the home. Service users commented that they were offered good food with a varied choice. Several service users commented that meals provided in the home are ‘good’ and ‘excellent’. Specific needs were catered for and plenty of extra food and drink was available throughout the day. Service users rooms and apartments are of a good standard with new decoration and furnishings, they are also able to personalise their room to their own taste. There is a core group of staff that have worked at the home for a few years and understand the needs of the service users well and are able to give them good support and care. Service users have their complaints and comments dealt with in a satisfactory manner. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: All of the service users have a care plan. These care plans are currently being changed to a new system, however in some service users files it was noted that information regarding the needs of some service users, including health checks by outside professionals was inadequate. This means the home was not able to show that all aspects of health, personal and social care needs of service user’s are identified and planned for. Individual activities programmes in consultation with the service user must be developed. Staff must be provided with more regular supervision and a yearly appraisal this is required to ensure that staff are provided with the leadership, guidance and support to ensure that service users are safe and their needs met. Records showed that not all staff was up to date with mandatory training, for example, moving and handling, fire safety, infection control and health. All staff must now be provided with this training this is needed to ensure the health, welfare and safety of both service users and staff. Staff must be provided with more training that is specific to the needs of the service users they are caring for, this being people with mental health problems. This is required to give staff the required knowledge to meet the needs of service users The manager advised the inspector that an independent company carried out yearly audit. Following the audit a report and action plan is then produced. Whilst this is a positive development this does not fully meet National Minimum Standard 39. The manager must now produce and make available an annual Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 7 development plan for the home. This is needed to make sure that everyone is consulted about the running of the home and to ensure continuous improvements are made. 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.V308604.R01.S.doc Version 5.2 Page 8 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.V308604.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Prospective service users have their needs assessed and are able to visit the home before their admission. EVIDENCE: The inspector examined the care records for four service users records; comprehensive assessments of needs were in place in two of the care files examined. Assessments for the other two service users were not available in the files. This matter was discussed with the manager gave an assurance that assessment reports had been provided for these service users. The manager is advised to obtain copies of missing reports. The inspector established from staff that full assessments of need were obtained before service users were admitted to the home. In the absence of a professional assessment staff were aware of the need to ensure they completed needs assessments. The home had a comprehensive assessment form to record their assessments. Nineteen service users returned a questionnaire; of these seventeen said that they were given adequate information prior to admission to the home. This means the homes takes appropriate action to ensure prospective service users Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 10 have access to required information to enable them to make informed decisions about the home capacity to meet their needs. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 11 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, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Although improvement in care planning was noted some service users care plans and risk assessments do not reflect their full range of needs and choices. Without this there is no assurance that service users health, social and personal care needs will be met. EVIDENCE: The inspector examined five service users care plans and other records associated with care planning. There is some evidence as to the involvement of service users in the planning of their care. Completed care plans and risk assessments were available in the files examined. Risk assessments for individual risks are not identified to enable staff to deliver appropriate care to a service user. For example; On examination of one-service users care plan it was noted that the planned care was not being undertaken at the time recorded and inadequate risk Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 12 assessments were in place for nutrition and the graph provided by a multi agency team was not being used, as the staff understanding of how to use the graph was very poor. The matter was fully discussed with the manager. The manager must ensure that all staff receive adequate training in the use of health calculating graphs, and that nutrition assessments and risk assessments are in place to ensure the appropriate care and support for the service user. Since the last inspection feedback from the manager and records indicate staff have not used physical interventions with the service users. However the manager confirmed that it might become necessary for staff to use physical interventions with a small number of service users. In such cases supporting care plans and risk assessments must be in place. Care plans and risk assessments must be agreed with the service users and the multi-agency care team. Plans must be subject to regular monitoring and review as detailed in the plan(s). Following discussions with staff and examination of records the recording of some service users visits to health professionals was not being recorded, for example: yearly health screening, blood tests, dentist, chiropodist, this is needed to ensure the health and welfare of the service users is being monitored regularly. Examination or the records identified that care plans for social and personal development needs were not available and must be developed with the discussion with the service user to enable them to maximise their potential within their needs. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16 &17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. The recreational, social, and personal development of service users is catered for with the exception of individual plans for the service users. Service users are encouraged to maintain links within the community by attending outside colleges and maintaining friendships. The routines of the home are flexible to meet individual service users needs. The meals provided to service users are of a good quality and offer variety and choice. EVIDENCE: The activities co-ordinator has been in post since the last inspection and has made improvements to the activities offered to service users. In addition a monthly budget has now been allocated to activities. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 14 Two service users are currently receiving further education courses at the local college. In discussion with the inspector several service users commented that whilst the provision of activities has improved over a period of time, available activities are not always what they want. The registered person along with the activities co-ordinator must on a regular basis consult with service users as to their needs around an activities programme. Examination of the records, discussions with service users and staff identified the need for individual recreational and social plans with the aid of past history and involvement of the service users. The registered person must ensure that this takes place. Two service users are currently receiving further education courses at the local collage. Staff involved in planning and organising activity programmes has not been provided with training to do this. This is needed to ensure relevant staff have the required knowledge and expertise to plan and implement activities programmes for people with complex needs. Since the last inspection the home has purchased a mini bus for service users, which enables them to choose their daily activities in the community with the aid of staff and the activities co-ordinator. Some members of staff were using their own vehicles for transporting service users to appointments outside the home. Records identified that these staff members have appropriate insurance cover and it was reported to the inspector that the owners provided the funds to make this possible. Nineteen service users returned a questionnaire of these; thirteen said they were allowed to make daily decisions on what they wished to do. Five service user commented that they were encouraged to make decisions some of the time. One service user said they were not encouraged to make decisions. The inspector examined the menus and the kitchen records including food temperatures and it was found that a good varied menu was available for three hot meals a day and a light selection at supper time. The menus contained a choice of foods. Discussion with service users and feedback obtained through returned questionnaires confirmed that a choice of food was provided. Service users reported that if they did not like something on the menu they would be offered an alternative. Hot drinks remain available at set times or on request. Service users described the quality and presentation of meals as ‘very good’ and ‘excellent’. The cook told the inspector that service users were involved Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 15 with menu planning. Records of resident meetings confirmed that meals are a regular agenda item. Since the last inspection the kitchens had been re-furbished and new equipment purchased, this included a new heated trolley to ensure meals are stored and transported at the correct temperature. The registered person must ensure that the appropriate risk assessments are in place for the transporting of hot meals and drinks, as these have to be taken up several steps to the dining room. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 16 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 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Arrangements for meeting the health care needs of service use are generally satisfactory although some improvement in care planning is required. Personal support is provided to service users in a way that respects their dignity and privacy. EVIDENCE: Service users spoken to said staff respected their privacy and dignity and they confirmed that where assistance with personal care was needed it was provided in the way they prefer. Service users said the way staff approached them was ‘good’, they also said listened to them. Through the inspector visit positive interactions between staff and service users was noted. All service users are registered with a GP. A record of dental and chiropody checks are maintained. GP visits are recorded in a diary these should also be recorded in the service users daily records. The mental health need’s of service users was being monitored by regular consultations with a visiting psychiatrist. Staff advised the inspector that Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 17 annual health checks are being carried out, with checks being documented in a diary. The inspector advises that these should also documented in the service users care records. Since the last inspection adequate weighing scales had been purchased. Records established that service users weights are being recorded on a monthly basis, however the care plan for one service user with nutrition problems stated the individual should be weighted weekly. Records established this was not happening. This potentially indicates that the service users health needs was being monitored effectively. On examination of a service user’s care plan it was noted that the planned care in respect of weekly blood monitoring was not being carried out. The registered person must ensure that monitoring as detailed in the care plan is carried out by staff. Failure to do this may result in the service users needs not being met. Information provided in the pre inspection questionnaire and discussion with the manager identified that only trained nurses administer medication. The pre inspection questionnaire stated that medication procedures are in place to support staffs practice. At this inspection visit medication systems were examined; policies and procedures were in place, which covered all areas of management. Storage of all medications was found to be satisfactory. External and internal medications were stored separately and stock control was effective. Staff advised the inspector that two weekly audits of medication and records was carried out and records seen confirmed this. The medication records of the service users in the case tracking were examined along with a selection of other records. The medication on the records was correctly recorded and corresponded to the label on the medication. Any changes to medication was authorised and signed by the psychiatrist or the GP. Following discussions with the staff and examination of staff records it was evident that most qualified staff need their medication training updating. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. The home had an Adult protection procedure is at present being updated. Adult protection arrangements need to be supported by a staff-training programme. EVIDENCE: A complaints procedure was in place. The inspector was made aware in discussions with service users and staff that they were aware of who to raise concerns to and who to contact to make a complaint. Fourteen service users recorded on their questionnaires that they knew who to approach to raise concerns and complaints, although two relatives had not seen a complaints procedure. The inspector advised the manager to ensure that all relatives have access to the complaints procedure. The protection of vulnerable adults policy is at present being updated. The staff spoken to by the inspector had an understanding of the procedure and who to report to when raising concerns about adult protection. Examination of a selection of staff training records identified that some staff have still not received adult abuse training. The registered person must ensure that all staff receive adult abuse training to ensure that staff are able to recognise adult protection issues and are able to report them in the appropriate manner. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 19 Policies and procedures were in place for physical restraint, although the manager advised the inspector that a new one was in the process of being written which was specific to the client group within the home. Discussions with staff and examination of records showed that there had been no physical intervention with service users recently, Staff training records showed that not all staff have received training in the use of physical intervention. The registered person must ensure that all staff receives the appropriate training to ensure that the welfare and safety of service users and staff is maintained. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this area is good. This judgement has been made using available evidence including a site to the service. There has been an appropriate and substantial improvement in the environment to ensure the comfort and safety of the service users. EVIDENCE: A complete tour of the premises was carried out. Since the last inspection all the service users bedrooms have been re-furbished to a satisfactory standard each having new carpets, curtains, furniture and bedding providing a more comfortable and attractive home for the service users to live in. Work in the laundry on exposed pipes has now been completed and the leaking pipe that was reported to CSCI has been repaired and the damage repaired. The kitchen has been re-furbished with new cupboards, fridges, dishwasher, hot water boiler and a new heated trolley for the meals. In addition to this the damaged fly screens and tiles noted at the last inspection had also been replaced. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 21 Adequate moving and handling equipment has been provided and staff have received training on the use of the equipment. Specialist equipment for one service user had also been provided and appropriate risk assessments. The inspector spoke to the person responsible for the maintenance of the home who kept adequate records of the work reported by staff that had been done and work that remained outstanding. The manager informed the inspector that new chairs had been ordered for the service users smoking lounge as the old ones were in a very poor condition. The home was clean and free from odours. Sixteen service users out of the nineteen surveys returned commented as to the cleanliness of the home. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 22 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 Quality in this area is adequate. This judgement has been made using available evidence including a site visit to the service. Recruitment records show that procedures for recruiting staff had improved, however supervision practice was noted to be inconsistent. This means the home was not able to fully demonstrate how the homes was assessing and monitoring the abilities of staff. EVIDENCE: An examination of five staff personnel records took place. Criminal Records Bureau disclosure checks had taken place prior to staff commencement to a post. References were obtained, although two references for a recently recruited member of staff were not dated or addressed to the homes manager. The manager must ensure that references are requested from the home by the manager. Internal induction records were available and the manager assured the inspector that induction training to Skills for Care Standards had been carried out with new employees, the records for these were currently being held at the companies’ head office. The registered manager must ensure that copies of these inductions be obtained to keep within the personnel files. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 23 Records showed that not all staff was up to date with mandatory training, for example, moving and handling, food hygiene, fire safety, infection control, first aid, health and safety and first aid. This remains an outstanding requirement from the previous inspection and must be addressed without delay. The inspector examined records for supervision and appraisals, these were being carried out, however in some cases supervision meetings for staff was not being carried out to the National Minimum Standard 36.4. The registered manager must ensure that supervision and appraisals are brought up to date as this will support staff and identify training needs. Examination of records showed that recorded staff meetings took place three monthly with staff attendance recorded. Examination of records showed that some support workers had had some mental health and challenging behaviour training and further training was planned. The home has in place a good NVQ training programme. The manager stated that 90 of care workers have achieved their NVQ. The home does not have a separate training budget, but a programme of inhouse training has been arranged. There are currently several staff vacancies at the home these being a deputy manager a care assistant and a kitchen assistant. The inspector recommended that a deputy manager be recruited to enable the manager to spend more time monitoring all the systems that are being used. Ten staff questionnaires were returned. Some members of staff were unable to state that they had regular supervision or adequate training. One member of staff said, “Staff are treated poorly and we work extremely hard.” Another member of staff said they felt that “more praise” should be given to them. Several staff members commented that their concerns were “dealt with and the situation sorted out”. Another comment made was that “problems were dealt with immediately and support given”. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 24 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, 39 &42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit. The manager of the home is a qualified experienced (mental health) nurse. Some of the systems that support the effective running of the home and the management of staff are still not fully operational. EVIDENCE: The manager has completed a recognised management course. Following discussions with service users and staff the inspector was aware that the manager had a friendly approachable manner. On examination of records some of the systems required for the effective overall management of the service were not fully developed for example, mandatory training, staff supervision and development. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 25 The manager advised the inspector that an independent company carried out yearly audit. Following the audit a report and action plan is then produced. Whilst this is a positive development this does not fully meet National Minimum Standard 39. The manager must now produce and make available an annual development plan for the home. This is needed to make sure that everyone is consulted about the running of the home and to ensure continuous improvements are made. There is a comprehensive health and safety statement and policies in place. The inspector has received a report from the fire officer who visited the home on the 12th May 2006. This report identified various observations and recommendations to be addressed. The fire officer returned to the premises on the 22nd September 2006. The inspector made a telephone call to the fire officer responsible for the report on the 29th September 2006 and all the recommendations had been addressed and the fire safety officer is to supply the manager with some information on the updating of the fire risk assessment. Inspection of water temperature records indicated that water temperatures were now being done on a monthly basis. Inspection of other records for example, fire alarm system check, emergency lighting were found to be up to date. Fire door weekly checks stated that all doors were closing correctly with the exception of three doors that were reported. The electrical wiring certificate was available for the inspector to see as was the portable appliance testing which was completed on the 22nd May 2006. The provision of mandatory training for example, moving and handling, fire safety, basic food hygiene, first aid and COSHH ensure safe working practices for staff, however, gaps in this training were found and the registered person must address these without delay Risk assessments for equipment in the home were not completed, please refer to comments detailed on page 16 of this report; these must be completed to ensure safe working practices to protect the health, welfare and safety of service users and staff. Service user files examined contained generic risk assessments, some of which contained little or no information. The inspector advised that where specific risks are identified for example: challenging behaviour more detailed risk assessments should be produced these should clearly set out the risks and action staff must take to eliminate or minimise identified risks. Inspection of accident records found that all accidents were recorded in an accident book and a complete report maintained in the individual service users files. A weekly accident report was sent to the company. Completed Regulation 37 notices were sent to the CSCI for major incidents, but where service user Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 26 died in hospital. The registered person must ensure that all deaths are where ever they happen must be reported. The records for service users finances were inspected. All benefits were paid into individual service user accounts. Some residents had appointees for example, court of protection, solicitors, family members and social services. There is a bank account made out in the name of Barrow hall for some service users which the inspector was informed was the only way the account could be set up with the appointees being the registered person and another member of staff as the second signature on the account. The manager must produce a procedure with the appropriate guidance of what to do and how it is to be done. Service users should always be given the opportunity to manage their own money if they are able to do so. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 27 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 Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 28 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 2 2 X X 2 X Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA36 Regulation 18 Requirement The registered person must ensure supervisions are carried out and recorded at least six times a year. (Timescales of 31/03/06 not met) The registered person must ensure all staff receive all the mandatory training that is required, including updates (Timescales of 28/02/06 not met) The registered person must ensure all staff is provided with an annual appraisal to ensure the training and development needs of staff are established. The registered person must produce an annual development plan for Barrow Hall based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. (Timescale of 28.2.06 and 31/05/06 not met) The registered person must ensure care plans address all the service users needs. These plans DS0000032128.V308604.R01.S.doc Timescale for action 30/12/06 2. YA32 18(1) c, 12(4) b 30/12/06 3. YA36 18 25/02/07 4. YA39 24(1) a&b, 30/01/07 5. YA19 12 30/12/06 Barrow Hall Care Home Version 5.2 Page 30 6. YA11 16 7. YA35 13 8. YA17 13 & 24 9. YA40 18 10. YA9 13 & 15 11 YA19 13 12 YA19 13 & 15 must be monitored on a monthly basis. The registered person must ensure that individual assessments for activities and recreational needs are developed along with the service user. The registered person must ensure that all staff receive training in relation to adult protection. This is an outstanding requirement (timescale of 31/03/06. The registered person must ensure when specific care monitoring of weight must be carried out. Nurses are also to be reminded of their responsibilities in this area. A check must be made on service user J records to ensure that these checks are being carried out. The registered person must ensure that all policies and procedures are updated on a yearly basis. The registered person must ensure where service users exhibit challenging behaviours, a detailed behaviour management plan(s) are developed. These must be subject to regular review and monitoring. (Timescale of 23/02/06 not met) The registered person must ensure that a system is introduced to record episodes of challenging behaviour and/or restraint are reviewed in a way that supports a review of each episode. The registered person must ensure that risk assessments and intervention plans are in place to support the use of physical interventions. The plans must ensure that a specific DS0000032128.V308604.R01.S.doc 25/02/07 25/02/07 30/12/06 25/02/07 30/03/07 25/02/07 25/02/07 Barrow Hall Care Home Version 5.2 Page 31 13 YA42 13 14 YA40 20 description of the interventions to be used. Risk assessments and care plans must be agreed with a multi-disciplinary care team and the service user. The registered person must ensure that risk assessments are in place for the use of equipment within the kitchen. The registered person must produce and make available a procedure for the management of service users finances. This must set out the homes arrangements for the way service users finances are managed. 30/12/06 31/12/06 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. 3. 4. Refer to Standard YA35 YA6 Good Practice Recommendations The registered person should staff are provided with training as detailed in NMS 35. The registered person should identify on care plans and risk assessments in the service users individual plans the person who has written it and the date implemented. The registered person should audit the home against the DS0000032128.V308604.R01.S.doc Version 5.2 Page 32 YA24 Barrow Hall Care Home 5. 6 YA19 YA40 7. YA35 requirements of the Disability Discrimination Act 1995, part 3. The registered person should ensure that annual health checks received by residents are recorded on their health records. The registered person should review the policies and procedure for missing persons, this policy should state the action to be taken in the case of the service user absconding. The registered person should ensure that a copy of the staff induction records are obtained from head office to be placed in the staff personnel files. Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 33 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.V308604.R01.S.doc Version 5.2 Page 34 Barrow Hall Care Home DS0000032128.V308604.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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