Archived: The Barn House

Updated 22 April 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 7 January 2016 and was unannounced. The inspection was carried out by three inspectors.

We had asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We used the information to corroborate our judgements.

We reviewed records held by CQC which included notifications, complaints and any safeguarding concerns. A notification is information about important events which the service is required to send us by law. We looked at documents which included seven people’s care plans, three staff files, training programmes, medicine records, and four weeks of duty rotas, menus and quality assurance records. We also looked at a range of the provider’s policy documents. We asked the registered manager to send us some additional information following our visit, which they did.

During the inspection we spoke with six people who used the service, four care staff, the registered manager, the registered provider, and a second manager. We also spoke to healthcare professionals after the inspection. We observed care and support in communal areas and looked around all areas of the service.

We last inspected The Barn House on 21 April 2015 and 15 July 2015 where the service’s overall rating was inadequate and it was placed in special measures.

Updated 22 April 2016

The Barn House is registered to provide nursing care and accommodation for up to 30 people with complex mental health issues, physical disabilities and people who may also be living with dementia. On the day of our inspection 23 people were living at the service, one of these people was in hospital.

The inspection took place on the 7 January 2016 and was unannounced. The inspection followed the Special Measures process to identify if the improvements required had been made.

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Barn House is owned and managed by the registered providers; one of the providers is also the registered manager, who was present on the day of the inspection visit. 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 and associated regulations about how the service is run.

The registered provider, registered manager and staff did not show an understanding of the needs of people with mental health issues, dementia and complex physical needs. The information the provider has placed on care websites states the service is a specialised service in supporting people with mental health needs.

Staff did not have written information about risks to people and how to manage these in order to keep them safe. They did not reflect the individual needs of the person and how their dementia, mental health or physical needs affected their daily life. One person had been diagnosed with epilepsy, but their care plan did not describe guidance to staff on how to manage the risks of them having a seizure. Another person experienced hallucinations but their care plan did not specify how these symptoms could be managed or what staff could do to provide support. At the last inspection, we asked the provider to take action to make improvements on assessing the risks to people’s safety; this action had not been completed.

People were not protected from the risk of abuse and improper treatment because staff were not always able to identify situations that constituted ill-treatment. People were left isolated in their rooms without social interactions. People’s changes in needs had not been identified which could place them at risk of harm by not receiving the appropriate care. People with mental health problems were not empowered to recover or supported to cope with their symptoms and engage in their own care.

The provider had not ensured robust recruitment checks were undertaken before new staff started work. Full employment histories and references for staff that had started work since July 2015 had not been undertaken.

Most people received their medicines when they needed them. Staff managed the medicines in a safe way and were trained in the safe administration of medicines for the majority of people. However one person had been assessed to receive their medicines covertly and staff were not following this guidance.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

There was a lack of understanding about decisions that people had the capacity to make. Staff did not have a clear understanding of how the person’s capacity should be assessed or how decisions should be made in the person’s best interest.

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 and hospitals are called the Deprivation of Liberty Safeguards (DoLS)

We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. Where people’s liberty may be restricted to keep them safe, the provider had not followed the requirements of the Deprivation of Liberty Safeguards (DoLs) because an urgent application under the Deprivation of Liberty Safeguards (DoLS) had expired and the registered provider and or registered manager had not submitted another urgent or standard authorisation to the local authority. This meant that people were being deprived of their liberty illegally. At the last inspection on 21 April 2015, we issued a warning notice under our enforcement process and asked the provider to take action to make improvements by the 15 August 2015, and this action has not been completed.

People were offered a basic choice of food in a written format. There was a choice of meals on offer, which was written on a white board in the main communal area. Kitchen staff told us they would prepare other food for people on request. People were asked about their food preferences for the following day’s menu which in most circumstances worked well however people living with dementia would be unlikely to remember what they had ordered. Staff did not offer choices in an alternate format for example showing a person with dementia two plates of food to choose from.

Staff did not staff consistently respect people or always treat them as individuals, focusing on their needs, abilities and achievements. We heard staff ask people constantly about task focused activities, for example, “Come and have your dinner” and, “Take your medicines.” At the last inspection on 21 April 2015, we asked the provider to take action to make improvements on staff empowering people to have their choices and this action has not been completed.

People who used the service did not receive treatment that was personalised specifically for them. We reviewed people’s care plans and found that care had not been personalised to meet people’s needs or individualised choices. They had not been reviewed on a regular basis and people were not involved with their own plan of care. One person said, “I’ve never seen a care plan.” There was no evidence that people’s care followed best practice guidance and was a combined approach looking at people medical, social, cultural and life goals. At the last inspection on 21 April 2015, we asked the provider to take action to make improvements in person centred care and this action has not been completed.

People were referred to some external health professionals such as the GP and SALT (Speech and Language Therapy) team. However if the person needed extra support with mental health issues it was not sought by the registered manager in a timely manner

Staff did not show an understanding of what people were interested in and what people could still do. We saw some people sitting for long periods of time without supportive interaction from staff. Supportive interactions are relationships and communications that we have with people that are affirming and help promote a person’s sense of self-worth. Best practice guidance shows one-on-one time is very important to having supportive and emotionally worthwhile social interactions.

People’s social and cultural needs were not met. There were people in the service of different cultural backgrounds and religions. These people were not supported to maintain an involvement in their religion or supported to eat the food of their choice from their cultural heritage. People who need care and support have experienced discrimination and stigma which can be detrimental to their mental health and wellbeing and excluded from making decisions for them simply because of their diagnosis or disability. Such as a diagnosis of schizophrenia or by having behaviour that might challenge. One person had been ostracized from their local pub because of the way they looked.

The registered manager and the ethos of the home did not support empower people to continue to fulfil their lives. Activities were limited to people who had capacity to become involved and were not appropriate for people’s ages. People who spent time in their rooms or were nursed in bed had no recourse to one to one or social int