Barley Brook is a care home in Wigan and is owned by Rosewood Healthcare. The home is registered with the Care Quality Commission (CQC) to provide care for up to 28 people. The home provides care to those with residential care needs, although a large number of people live with dementia.
We last visited the home on the 07 and 09 of July 2014 during the testing phase of the new inspection methodology. The service was rated as ‘Inadequate’ during this inspection and we issued seven compliance actions with regards to care and welfare, safeguarding, medication, suitability of the premises, records, supporting workers effectively and monitoring the quality of service. We also issued a warning notice for regulation 10 with regards to monitoring the quality of service effectively.
At the time of our inspection, the manager was new in post and as such, was not yet registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found that the registered person had not protected people from the risks associated with monitoring the quality of service, medication and record keeping. These were breaches of regulations 10,13 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These relate to regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment and governance.
At our last inspection we had concerns about how medication was handled in relation to hospital discharge and covert medication. During this inspection we had further concerns with regards to how people’s medicines were handled. We found unsafe processes around the administration of medicines from the Bio dose system whereby medication could not easily be identified by staff. For example where specific administration instructions were required. This put people at risk of errors in selecting the wrong medication and also not receiving the medication in a safe manner.
We found improvements were required to handwritten medication records (MAR) to ensure staff were aware of any specific warnings relating to a certain medication so that administration was safe. We found one example where a person was put at risk with their medicines as the member of staff did not know this information.
We found examples of medication being given without due regard to any specific warnings. This put people at risk of the medication either not working in the best way or at risk of experiencing side effects. One person had run out of medication and not received a dose of the medicine as needed in the morning. This identified poor management and ordering of repeat medication, which put this person at risk with a delay in receiving the medicine. It was a particular concern that some people were given medicines late in the morning, as they were sleeping when staff first attempted to administer. However, no advice had been sought to ensure safe administration.
There was no consistent information available regarding PRN (when required) medication to support staff to administer medicines safely. Due to the lack of supporting information, it was unclear whether people received these medicines at the time they needed them. It was of particular concern for those people who could not clearly communicate their needs, as there was no evidence that their needs had been observed. The manager informed us that she was in the process of drawing up pain relief treatment plans which would help to address this concern.
At our last inspection we had concerns with regards to the safety of the premises and the fact that people had been able to access areas of the home which could place them at risk. We saw improvements in this area, as the home had introduced ‘key pad’ locks to areas of the home including the cellar, staircase and court yard at the rear of the building, which prevented potential trip hazards to people. One person had been able to leave the building due to a window only being secured with a chain as opposed to a window restrictor. During the inspection we found windows had now been fitted with suitable window restrictors, which prevented people leaving the building in a potentially unsafe manner. There were also specific risk assessments in place to cover these areas with daily, weekly and monthly checks in place.
At our last inspection we found appropriate Deprivation of Liberty Safeguards (DoLS) applications had not been submitted to the local authority when people had attempted to leave the building. The manager now kept a checklist in the office to show which people came under a DoLS and if an application had been made. In addition, people had specific DoLS care plans in place where necessary.
At our last inspection we had concerns about night time staffing levels and the fact that with no senior member of staff available, there was nobody to give medication to people such as pain relief. During the inspection we looked at staff rotas and saw senior care staff had been added to the night time rota and were supported by two care assistants. We were able to see these staff were on shift when we first arrived at the home in the morning.
We looked at how staff were recruited and looked at six staff personnel files. Overall, we found suitable checks were undertaken before staff began work, including ensuring two references were sought and DBS checks undertaken. However, we found one member of staff had only personal references on their file and none from previous employers, despite having been employed elsewhere previously. We raised this with the manager who told us this member of staff had started working at the home before she had commenced the role as home manager, but would ensure appropriate checks were made in the future.
Staff supervision at the home was not consistent. Of the six files we looked at, only two had received supervision despite having worked at the home for several months. We raised this with the manager to see if the records were located elsewhere, however we were not shown them. Following our inspection, the manager sent us a supervision matrix which showed the majority of staff had received supervision in late February 2014 and would receive further ones every three months.
At our last inspection we felt the layout of the home was not suitable for those living with dementia. During this inspection we undertook a tour of the building to see what improvements had been made. Toilets, the lounge area, bathrooms, the dining room and ground floor were all clearly sign posted and supported by pictures, for people who may have difficulty with cognition. The sample of bedrooms we looked at had a large picture of the person living there and the number of their room was clearly displayed. The colour of people’s doors was very similar to the colour of the walls, which could present difficulties for people in successfully finding their bedroom. We raised this with the manager who told us plans were in place to ensure doors clearly stood out from the rest of the home decoration and were easier for people to find.
At our last inspection we observed that there were a number of missed opportunities for interaction, between staff and people living at the home. During this inspection we saw that on occasions, this still presented an issue. We spent time observing care in the main lounge area of the home during the morning of the inspection. At this time, there were six people seated in the lounge area and on several occasions, staff walked straight through the lounge area from the kitchen area without acknowledging people or asking if there was anything they needed. We raised this issue with the manager who said she would re-iterate this to staff.
During our inspection we observed two people who struggled to communicate verbally, both with staff and other people living at the home. Their speech was unclear and it was difficult to understand what they were saying. We found there were no specific communication care plans in place to demonstrate what staff needed to look for to understand their requirements and what potential body language to look out for. We raised this with the manager who told us they would ensure these care plans were in place following our inspection.
At our previous inspection we identified concerns with the homes record keeping. Whilst looking at people’s care plans we became aware that certain people needed to be weighed weekly, although records in care plans did not support that this had taken place. Additionally, we found three people required to be re-positioned at regular intervals and again, records did not support that this had taken place in line with the necessary timescales. We raised this with the manager who was confident these tasks had been completed by staff, but that accurate records had not been maintained.
At our previous inspection, we felt people’s care plans could have been more person centred, capturing things of importance to them such as likes, dislikes and their life histories. In response to this, the manager told is they had introduced ‘This is me’ documents for each person living at the home. This detailed people’s life story, photos of when they were younger, where they were born, hobbies/interests and war time experiences.
We saw a system had been introduced called ‘You said, we did’. This was a survey sent to staff, people who lived at the home and relatives asking how they would like things to be improved within the home. This asked questions about laundry services, food/menus and the general cleanliness of the home.
There were a range of audits undertaken at the home. These covered pressure sores, bed rails, medication, infection control and falls. Additionally, there were regular checks of window restrictors, fire exits, the courtyard door, building maintenances, step ladders and wheel chairs. Despite these audits being in place, there were no systems in place to check other important aspects of the service such as weekly/monthly weights, people being re-positioned and staff supervisions were being completed when they should. Additionally, the medication audits in place did not highlight the shortfalls we had identified.