Archived: Barham House

Barham House is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and care provided, and both were looked at during the inspection. Barham House accommodates up to 23 people in one adapted building. The building is an historic older building providing large communal areas and extensive well kept gardens. At this inspection, 21 people were living at the service.

The registered manager worked at the service each day and was supported by a deputy manager. A registered manager is a person who has registered with CQC 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 last inspected Barham House in September 2017 when three continued breaches and two new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. We issued requirement notices relating to a lack of robust safeguarding procedures, poorly managed dietary needs, a failure to adhere to the principles of the Mental Capacity Act (2005) and a lack of activities to meet people’s needs. We also issued a warning notice in relation to insufficient staff on duty to meet people’s needs.

At our last inspection, the service was rated ‘Requires Improvement’ overall and in each of the five key areas. This was because there continued to be shortfalls in the service that were identified in the previous inspection. At this inspection, although improvements had been made, there were two further breaches of Regulation and other areas identified that needed improvement. The breaches of Regulations related to failing to meet people’s dietary support needs, some incomplete records and auditing procedures that were not wholly effective. Therefore, this is the third consecutive time the service has been rated Requires Improvement.

People were generally satisfied with the food provided, however, kitchen staff were not always notified of people’s dietary needs. Food was not always prepared and plated in an appetising way and, where people needed adapted plates or cutlery to help them eat more independently and with dignity, this did not always happen.

Record keeping in care plans needed to improve to more clearly document people’s current condition. In addition, control of records about the maintenance of equipment within the service and some checks required for some staff working at the service required more effective oversight. Auditing processes within the service were not sufficiently detailed or effective to identify and drive forward continuous and autonomous improvement.

Medicines were managed safely, there had been no errors in administration and people received their medicines when they needed them. Staff competency had been checked. However, staff needed to ensure disposal of all medicines were fully accounted for. This is an area for improvement.

People were protected from harm by staff who were trained to recognise signs of abuse. However, staff were not continuously aware of risks presenting the potential for unauthorised access to the service and for people using the service to leave unnoticed. This is an area for improvement.

Most people and visitors told us they knew how to complain if they needed to. However, providers are required to meet people’s information and communication needs. Therefore, in settings supporting older people, including some with dementia, providers should develop complaints information to at least be available in larger bold print. Similarly, complaint and client survey tools may be more accessible to some people if, for example, they included facial expressions for, where possible, people to gauge their own level of satisfaction, rather than just a narrative and tick box. These are areas identified for improvement.

Pre-assessments for people moving to the service were comprehensive. Potential risks to people’s health and welfare were identified and there was guidance for staff to follow.

Accidents and incidents were analysed and measures were in place to reduce the occurrence of repeated incidents. Staff were recruited safely, received appropriate training and worked with healthcare professionals to keep people as healthy as possible and deliver effective care.

People were supported to have maximum choice and control of their lives and in the least restrictive way possible. Policies and systems in the service supported this practice.

People told us that staff were kind and encouraged them to be as involved as possible in their care and, where people wanted to, they took part in a range of activities.

People were supported to express their end of life wishes. Staff were aware of people’s religious beliefs and received training to support people at the end of their life and keep them comfortable.

The culture within the service was open and transparent. Staff meetings enabled discussion of care practice and how staff could work towards improvement.

The registered manager attended training and local forums and worked with the local commissioning group and safeguarding authority to ensure people received joined up care.

The building was adapted to meet people’s needs. Staff completed checks on the environment and equipment, these helped to ensure people were safe.

Services that provide health and social care to people are required to inform CQC of important events that happen in the service. This meant we could check that appropriate action had been taken. The manager was aware that they needed to inform CQC of important events in a timely manner and had done so.

It is a legal requirement that a provider’s latest CQC inspection report rating is displayed at the service where a rating has been given. This is so that people, visitors and those seeking information about the services can be informed of our judgements. The provider had conspicuously displayed the rating in the reception area of the service. The provider did not have a website to display the rating.

At this inspection two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. You can see what action we have asked the provider to take at the end of the report.

Barham House is registered to provide nursing and personal care for up to 23 people .There were 19 people using the service during our inspection; who were living with a range of health and support needs. These included; diabetes, catheter care, dementia; and people who needed support to be mobile.

Barham House is a detached house situated in the village of Barham near Canterbury, Kent. The service had a very large communal lounge available with armchairs and a TV for people and a separate, quieter lounge, where people could entertain their visitors. There was a secure enclosed garden to the rear of the premises, with far-reaching views across open countryside.

A registered manager was in post. A registered manager is a person who has registered with the care Quality Commission to manage the service. 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.

Barham House nursing home was last inspected in January 2017. At that inspection it was rated as Requires Improvement overall but Inadequate in the well-led domain. Following that inspection we served the provider with a Warning Notice.

At this inspection we found an improving picture overall. However, further work was needed to continue to improve the quality and safety of the service people received.

There were not enough staff to meet people’s needs during the inspection and on some dates prior to it. Risk assessments varied in quality and detail; and actions to reduce risk were not always carried out in practice. Some unexplained injuries had not been discussed with the local safeguarding authority to allow them to consider independent investigation of them.

The laundry floor and walls remained chipped and difficult to clean to a hygienic standard.

Not all people received support to eat in line with care plan directions and special dietary needs were not always observed. The principles of the Mental Capacity Act (MCA) 2005 were not consistently applied to ensure people’s rights and choices were respected. Deprivation of Liberty Safeguards (DoLS) had been applied for by the registered manager where necessary.

Staff were not always considerate of people’s choices or the impact of what they said to them. . There were not enough activities to offer people social stimulation.

Complaints were well-recorded but actions arising from them were not in evidence during the inspection. Care plans were person-centred but had sometimes been over-written which made them confusing.

Auditing had improved overall and was now more effective in highlighting shortfalls. Feedback had been sought in a variety of ways and actions had been taken when issues were raised. Staff reported good teamwork and improved leadership and people said the registered manager was visible and approachable.

Medicines were managed safely and environmental risks had been assessed and minimised. The service was clean and tidy; with no odours present.

Recruitment processes were robust and staff training had improved since our last inspection. Staff received regular supervision and appraisal.

People’s health care needs were monitored and met; including their weight. Meals appeared nutritious and plentiful and people received enough to drink. People’s independence was promoted through the use of special equipment such as plate guards.

We found a number of breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of this report.

Barham House is registered to provide nursing and personal care for up to 23 people .There were 22 people using the service during our inspection; who were living with a range of health and support needs. These included; diabetes, catheter care, dementia; and people who needed support to be mobile.

Barham House is a detached house situated in the village of Barham near Canterbury, Kent. The service had a very large communal lounge available with armchairs and a TV for people and a separate, quieter lounge, where people could entertain their visitors. There was a secure enclosed garden to the rear of the premises, with far-reaching views across open countryside.

A registered manager was in post. A registered manager is a person who has registered with the care Quality Commission to manage the service. 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.

Barham House nursing home was last inspected in September 2014. At that inspection it was found to be compliant with Regulations.

At this inspection we found that the service required improvement in all areas. Although we saw some features of good care, there were other aspects which fell below acceptable standards. We received mixed feedback from people and relatives about their experiences of the service.

Some risks to people’s safety and well-being had not been appropriately reduced. This included those associated with people who were unable to use call bells, people who needed support to reposition themselves to prevent pressure wounds and risks around eating and drinking. Environmental, fire and maintenance risks had however been properly addressed.

Medicines had not always been stored securely, and auditing had failed to pick up on missed staff signatures to show that people had received their medicines. Medicines were well-organised in trolleys and regular recordings had been made of the temperature of the medicines room and fridge.

Some areas of the service were not appropriately hygienic; although a planned deep clean took place following the first day of our inspection.

Recruitment processes were robust but there were not always enough staff on duty to meet people’s needs. Staff received regular training and supervision but this had not highlighted some shortfalls in staff knowledge or practice.

Safeguarding processes were understood by staff. Accidents and incidents were properly recorded but actions taken to prevent recurrences were not always documented or effective.

People had plentiful, nutritious meals but did not always receive the support they needed to eat them. Records of what people ate and drank were not always accurate and posed the risk that poor intake would be overlooked. People had input from the GP, tissue viability nurse (TVN), podiatrist, dieticians and other professionals.

Staff were knowledgeable about the Mental Capacity Act (MCA) 2005 and worked within its principles. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes are called the Deprivation of Liberty Safeguards (DoLS). The registered manager understood their responsibilities around (DoLs) and had made a number of applications to the proper authority.

Staff were mostly caring and kind to people but the attitudes of some staff were disrespectful at times. There were limited activities for people day to day, although those people who were able went on occasional outings.

Complaints were managed appropriately by the registered manager and people and relatives knew how to raise concerns if necessary. People and relatives feedback was sought through a comments book and survey; although responses had been few.

There had been insufficient management oversight of the service and audits had not always been effective in identifying shortfalls in quality and safety.

We recommend that the provider sources suitable picture menus to provide the appropriate support for people living with dementia or other memory impairment.

We recommend that the provider updates diabetic care plans with information about individual blood sugar level parameters.

We recommend that the provider sources reputable end of life care training for staff and updates care plans with greater detail about people’s choices and decisions.

We found a number of breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of this report.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We viewed all communal areas of the home and some of the bedrooms. We saw that the premises were clean in all areas, and were satisfactorily maintained. The home was an old, Grade 2 listed building, and a programme of on-going maintenance was in place.

We found that there were systems in place to check general risk assessments for the building, and individual risk assessments for the people who lived there. These contained clear directions and were up to date.

The manager showed that she understood her responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The manager said that it had not been necessary to make any applications to deprive someone of their liberty for their own safety.

We inspected medicines management and found that policies and procedures were followed accurately, and there was safe storage and administration of medicines.

Is the service effective?

People living in the home had care plans in place which provided comprehensive details of their nursing and care needs. These were written to address people's individual needs, and showed people's personal preferences in regards to their care. We saw that people or their representatives had been involved in their care planning. People were supported by other health and social care professionals to provide them with additional care or treatment as needed.

The home provided people with a variety of different foods to meet their dietary needs. People said that they had plenty of choice and that they liked the food. One person said 'The trouble is it is so nice, and we get too much food really!' The catering included home-made cakes, fresh fruit and vegetables, and snacks available at any time.

Staff training records confirmed that staff were kept up to date with training in required subjects such as moving and handling, infection control, and health and safety. Most care staff had been trained in National Vocational Qualifications (NVQ) or Qualification Credit Framework (QCF) training, levels 2 or 3 in health and social care. Other staff were in the process of studying for these formal qualifications.

Is the service caring?

People that we talked to said that they were happy living in the home. Some of their comments included 'It is very nice here, they look after us well'; and 'I have made friends here, and the staff are good.'

We saw from reading care plans that people's individual preferences were discussed and documented; and we observed that staff asked people what they wanted to do and where they wanted to go. People's life histories were included in their care plans so that the staff could become familiar with their previous lifestyles and hobbies and support them accordingly.

Is the service responsive?

People said that they were able to carry out their preferred activities. We saw that some people were reading books or newspapers; watching television and completing word puzzles. People were able to sit in the lounge, conservatory or garden; and were able to go out to shops and the local pub as they wished. Some group activities were organised during the week for people's entertainment.

The nursing staff ensured that other health professionals were contacted for visits or advice in regards to people's on-going health care. They informed people's relatives of their changing health needs as necessary.

People said that if they had any concerns they would talk to one of the nurses or the manager. They were confident that they would be listened to, and that their concerns would be dealt with appropriately.

Is the service well-led?

The care staff told us that they worked in teams, so that they knew how each other worked and could support each other and work together. They said that the manager was supportive and approachable, and they could ask for advice at any time. We saw that the manager and deputy manager worked alongside the care staff and were easily accessible.

The home had systems in place to monitor the on-going effectiveness of the service. This included obtaining people's views through one to one conversations, and through questionnaires. Auditing procedures were carried out at regular intervals such as health and safety checks, care plan audits, accident and incident reporting, pressure sore audits, and medicines audits. These processes identified if any changes were needed, and these were then implemented.

The manager told us that the provider considered any requests that she made for new equipment, furnishings or repairs, and was supportive in providing these as necessary.

We found that since our last inspection in February 2013 improvements had been made to the environment including checking the electrical and fire system. People who used the service lived in an environment that was safe, accessible and promoted their well-being. People told us that they liked living at the service.

Staff recruitment records showed that new staff had been thoroughly checked to make sure they were suitable to work with vulnerable people. Systems were in place to monitor the service that people received to ensure that the service was satisfactory and safe. People told us they did not have any complaints but would not hesitate to speak to the manger or staff if they had any concerns.

We found records to show how people's health needs had been assessed before they came to live in the home. These included information from health and social care professionals to make sure the home could provide the care people needed.

The staff rota showed that staffing numbers had recently been increased to make sure there was enough staff on duty and people's needs were being met.

People told us that they were satisfied with their bedrooms and they were clean and tidy. One person said: "I have a brilliant lady who keeps my room nice and clean". We saw staff spent time with and empathised with people by responding to them respectfully and positively.

We found that there were insufficient systems in place to make sure the premises were as safe as possible. Fire drill records were not consistently recorded and the fire risk assessment had not been updated for since 2011. There was also a lack of environmental risk assessments and maintaining the temperatures of the water. There were also areas of the home that needed redecorating and repair. Relatives told us that the home 'could do with a lick of paint'.

People told us they knew how to complain but did not have any concerns or issues at the time of the visit.