Inspection on 12/05/04 for Across The Bay

Care Home For Older PeopleAcross The Bay479 Marine Road Morecambe Lancashire LA4 6AFAnnounced Inspection12th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Across The Bay Address 479 Marine Road, Morecambe, Lancashire, LA4 6AF Email address Name of registered provider(s)/company (if applicable) Mr John Graham Haslam Mrs Jennifer Mary Bailey Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 24 Tel No: 01524 410625 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (24) Registration number F090000005 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 26/11/03 If Yes refer to Part CAcross The BayPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 312th May 2004 10:00 am Mr Ajam Auckburally Mr Simon Hill (Pharmacist Inspector)ID Code079356Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionAcross The BayPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementAcross The BayPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Across The Bay. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Across The BayPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Across The Bay is a care home for service users of both sexes who are 65 years old and over. The home is situated facing the promenade in Morecambe and close to Happy Mount Park. The home can accommodate a maximum of 24 service users in 14 single and 5 double bedrooms. The home is staffed around the clock to care for the service users. Facilities at the home include a large comfortable lounge, a smaller lounge and a dining room. The home has several floors and a passenger lift is available to access all the floors. A sitting area is available at the front of the home and facing the sea front. There were eighteen service users residing at the home at the time of the inspection. They all said that they are well looked after and that all the staff are kind and helpful.Across The BayPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Choice of Home: Standards 1-6 (1,3,4 and 5 assessed) All met. A statement of purpose and a service user guide have been produced by the home. Contracts with the home are in place for all service users. Opportunities are provided for service users to visit the home prior to making their choice. Service users told the inspector that they were given the opportunity to visit the home prior to admission and were given adequate information about the services and facilities provided at the home. Health and Personal Care: Standards 7-11 (7,8,9 and 10 assessed) All except 9 met fully. Care plans defining how the needs of service users are being met are in place. Adequate arrangements are in place for the provision of health services to service users. Staff were able to discuss the importance of privacy and dignity throughout life and at the end of it. The pharmacist inspector has made a thorough inspection of the policies and procedures for medicines. His detailed report is included in the main report at Standard 9. Inspection comment cards returned by two doctors who regularly visit the home were positive about care provided and attitudes of staff. Daily Life and Social Activities: Standards 12- 15 (all assessed and met) Service users were positive about the social life within the home. Service users expressed complete satisfaction with services and facilities provided at the home. The provider said that outings and shopping trips are organised on an individual basis and according to service users wishes. Arrangements are in place for service users to access spiritual leaders. Complaints: Standards 16-18 (16 and 18 assessed and met) A procedure for the recording of complaints was in place. The home had received no complaints since the last inspection. Policies in respect of the protection of adults and whistle blowing were in place. Environment: Standards 19-26 (19,23, and 25 assessed and met). The building is in a good state repair and there is a rolling programme of maintenance and upkeep. Some of the heating radiators have been fitted with low heat surface covers and hot water delivered is regulated at the recommended temperature to all hot water outlets directly used by service users. The home was found to be clean and in good hygienic order. Staffing: Standards 27-30 (27and 28) 27 met and 28 partly met. Staffing met the minimum levels required and recruitment policies took account of the need for protection of service users. A programme of training was in place. Across The Bay Page 6 Management: Standards 31-38 (31,33,35 and 36 assessed) 33,35 and 36 met and 31 partly met. The proprietor has many years experience of running a care home and is currently doing his Registered Managers Award. The inspector found that the staff and the management of the home are fully aware of the needs of all the service users in the home and provide the help and assistance to meet those needs.Across The BayPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 2 23 18 OP25 OP28 All central heating radiators and pipes must be fitted with low heat surfaces. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) by 2005. 30/6/04 2005Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Across The BayPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 13(2) OP9 The manager to ensure that all medication being self-administered is securely stored and 12.6.04 a disclaimer obtained from the relevant service user. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) by 2005. All central heating radiators and pipes must be fitted with low heat surfaces. 2005218OP28323OP2531/12/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 OP9 OP9 A policy to be written and adhered to stating medication should be retained for seven days following the death of a service user. Regular formal advice visits to be obtained from the community pharmacist. Page 9Across The Bay 3 4 5OP9 OP9 OP9Received medication is accurately recorded on the MAR. Controlled drugs to be stored and recorded according to current recommendations and regulations. The manager is encouraged to obtain accredited training for all staff that administer medication.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Across The BayPage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES NO NO YES YES YES YES YES YES NO YES NO YES NO YES 15 1 X YES YES YES YES 18 X 12/5/04 10.00 4Across The BayPage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Across The BayPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 229 To (£) 338Any charges for extrasYESPERSONAL ITEMS If yes, please state what the extras are: 3 Key findings/Evidence Standard met? The provider has produced a statement of purpose and a service user guide. These documents give details of all the facilities and services provided at the home. The inspector examined these documents and found them to be current and accurate. Some of the service users the inspector spoke to said that they were aware of these documents. The service users said that they are well cared for and that all the staff are kind and helpful. The provider said that copies of inspection reports are available for staff and service users to read.Across The BayPage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The provider said that service users are only admitted to the home following a full assessment. The pre admission assessments are done by senior care staff and they assess the suitability of the service users wanting to come to Across The Bay. The purpose of the pre admission assessment is to match services provided at the home to service users needs. A service user recently admitted on respite care to the home said that her daughter visited the home on her behalf to ensure that Across The Bay was the right home for her. She said that she is very satisfied with all the services and the care she receives at the home. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The inspector spoke to the staff on duty and they said that they care for all the service users with dignity and according to their assessed needs. They added that where required, other professionals such as doctors, nurses and other specialists are consulted to provide assistance. The personal files confirmed that assessed needs are being met. Service users the inspector spoke to said that all the staff are kind and helpful and are always available to care for them. They added that if they need to see a doctor or other health professionals, the staff will arrange it for them. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The provider and the staff said that ideally prospective service users are given the opportunity to visit the home and meet other service users prior to admission. The provider said that in most instances it is the families of prospective service users who would visit on their behalf. The purpose of the visit is to enable the service users or their families to assess whether the facilities and services at the home can meet their particular requirements.Across The BayPage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This service is not provided at the home.Across The BayPage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The assessments and care plans for all the service users are done using a written format The inspector examined two of the assessments and care plans of the two residents being case tracked. Case Tracking is a method by which the care and services of a small group of service users are examined closely. This is done by speaking to the service users where possible, reading documents, observing, speaking to staff and relatives and other professionals where appropriate. The written information provided was current and well detailed. It was easy to read and understand. The staff the inspector spoke to said that they contribute to the care plans. Contributions to complete the assessments are also received from the service users, relatives and where appropriate other professionals such as doctors, nurses, social workers etc. The care plans are reviewed monthly and more regularly where requiredAcross The BayPage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 3 X3 Key findings/Evidence Standard met? The accident book was examined and it showed that appropriate actions were taken following all accidents. The service users said that the staff are always on hand if they have an accident and take good care of them. A written policy on how to deal with accidents was seen by the inspector. The service users individual care plans and assessments indicated that their health and well-being are monitored and attended to. Service users have access to appropriate health care services including District Nurses, Chiropodists, Opticians and other specialists.Across The BayPage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Policies and procedures: The policies and procedures seen within the home were of standard format and contained relevant information on medicine handling. Current guidance from the Royal Pharmaceutical Society of Great Britain on The control of medicines in care homes would be of benefit to ensure that all staff are aware of current issues in medicine handling. The national minimum standards (9.11) state that medication should be retained for seven days following the death of a service user, this was not in the policy and evidence was seen of the home returning medication immediately. Self-medication policies and procedures were in place but on inspection it was clear that the staff did not follow these for all relevant service users. Self-medication: A service user who was self-medicating was interviewed by the pharmacist inspector. She stated that there was no lockable space within her bedroom and that she could not lock her room whilst she was not in it. The administration records did not reflect this service users medication, it is recommended that the owner obtains medication administration records for all service users; These can clearly state that the service user is self-medicating whilst maintaining an accurate record of medication held in the home. Record Keeping: The medication administration records (MAR) were computer generated supplied by the community pharmacist. The records were clear, accurate and signed at the time of administration. Medication returned to the pharmacy was recorded in a dedicated book. The receipt of medication was not clearly recorded, it is suggested that the staff sign the MAR at the time of receipt to help create a good auditable system. The controlled drugs register evidenced was not suitable to this setting and as such made accurate recording difficult. Receipt of controlled drugs was not recorded appropriately and records were often made prior to administration. It was clear that a new appropriate register and staff training on its use would improve this situation. Storage of medication Medication was stored within a dedicated cupboard, the locks on this cupboard were recognised as not being robust enough. The manager as such acted immediately and new locks were being fitted as the inspector left the premises. No medicines were seen that required refrigeration, the manager was advised to use a lockable container for items requiring short term refrigeration. Controlled drugs were being handled at the time of inspection, these were stored in a suitable safe but this was not fixed to the wall. The manager acted immediately by moving the safe to a more suitably secure location. Administration of medication: Two senior members of staff had carried out an accredited training course and this had been cascaded down to other staff. All internal training had been documented. The national minimum standards state that all staff administering medication should receive accredited training (9.7), the manager is encouraged to obtain this training for all staff. The manager is also encouraged to obtain formal advice visits (9.9) from the supplying Across The Bay Page 18 community pharmacists, funding for the pharmacist is available from the appropriate Primary Care Trust. The staff demonstrated a system that showed due care and attention, records were clear, photographs were with the MAR, patient information leaflets were accessible for all medications and the home saw all prescriptions prior to the pharmacist dispensing.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The staff the inspector spoke to said that they respect the service users privacy and treat them with dignity. They said that they always knock before entering service users bedrooms. They said that where service users can respond to a knock on the door, they would wait to be invited in. The service users the inspector spoke said that all the staff treat them with respect and dignity. They said that the staff always ensure that bathroom door is shut when providing personal care. Service users have a choice on how staff addressed them, either by their first names or their titles such Mr, Mrs or Miss and they said that they preferred first names, as it is friendlier. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The inspector observed during the inspection, the flexibility with which the service users went about their lives unhindered by the routines. The staff were observed to be courteous and obliging when speaking to the service users. They said that the service users have absolute choice in what they do. Activities are planned according to the wishes of the service users. The staff said that the most popular communal activity is playing bingo with prizes provided by the home. A physiotherapist has been employed by the home to encourage service users to do light exercises. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Service users who are able and willing can go out when they want. There are no restrictions on families and friends visiting the home. The staff provide help and assistance for service users who are unable to go out by themselves. The inspector spoke to a relative who was visiting her mother. She said that she was very pleased with the services at the home. She said This home is caring, efficient and friendly.Across The BayPage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The service users said that they are free to do what they want. They said that they can use their rooms and other facilities in the home freely. One of the service users was in her room when the inspector went round the home. She said that she likes the added privacy her room afford her. The service users said that they could bring as much of their own possessions as they wanted and the rooms visited by the inspector confirmed this. Many of the rooms were personalised with service users own furniture, photographs and other personal belongings. Service users who are able and willing can look after their own finances. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The service users said that the food provided is good and that they get plenty to eat. The inspector had lunch with the service users and the meal was Chicken Casserole and vegetables. The meal was served hot and looked appetising. A choice of meals is not provided at lunchtime but the service users the inspector spoke to said that if they do not like something, then the cook will always provide something of their choice. A wide choice of food is offered at breakfast time and teatime. Breakfast include a cooked breakfast for those who want it. The home can cater for people with special diets such as diabetics, low fat and any other reasonable request is considered. The dining room has recently been redecorated and looked very pleasant.Across The BayPage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? A written complaints procedure has been produced and is included in the Statement of Purpose. It is available to all service users and their families. It clearly describes the process someone should take in the event of a complaint and includes the contact point for the Commission for Social Care Inspection. The service users the inspector spoke to said that they had no complaints about their care and if they had they would speak to the owner who will sort them out. They said that all the staff are kind and helpful.Across The BayPage 22 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X3 Key findings/Evidence Standard met? There is a written policy on Adult Abuse which explains the procedures staff should take in the event of an abuse taking place. All the staff are made aware of the abuse policy as part of their training. This policy was examined and found to be easy to understand and described the different types of abuse that a vulnerable person can suffer. The staff said that they are aware of the abuse procedure, but in most instances will consult the management of the home if they need to know more about it.Across The BayPage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Across the Bay is situated in Morecambe and facing the sea front. The home is an old building and has several floors. A passenger lift is available for residents to access all the floors. They can use lift independently if they are able and willing. The service users said that there are no restrictions as to where they can go in the home. They said that they are free to move around as they wish. The owners said that there is a rolling programme of maintenance and decorating. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO YES 14 1 5 X 8 6X X 3 23 Key findings/Evidence Standard met? The home provides accommodation as described above. The room sizes and ratio of single and double rooms are in line with recommendations made by the registering authority.Across The BayPage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? The hot water to the all the bath and hand wash- basins is delivered at the recommended temperature of 43ºC. Some of the heating radiators have now been fitted with low heat surface covers as required by this standard.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 12 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 5 1 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X3 Key findings/Evidence Standard met? The above figures were supplied by the provider at the time of the inspection. The staffing level is in line with recommendations made by the previous registering authority. There were three care staff, the provider and a cook on duty at the time of the inspection.Across The BayPage 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 2 11 2 Key findings/Evidence Standard met? Two care staff have completed their NVQ (National Vocational Qualification) training at Level 2. Six more staff have also completed the same course and are waiting for their certificates to be issued. There is a requirement that the percentage of care staff completing their NVQ level 2 training reaches 50 by the year 2005. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 29 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The proprietor has worked at the home for several years and is well experienced in managing the home. He has produced all the current policies and procedures as required by the National Care Standards Commission. He has completed NVQ level 4 in care and is currently doing his Registered Managers Award. This must be achieved by 2005. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 30 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 4 Key findings/Evidence Standard met? The proprietor said that there is a continuous monitoring of the business and the premises. Service users opinions are sought on a informal basis and this is done by regular contact with them on a daily basis and formally by using a questionnaire. The positive result of the survey was seen during the previous inspection. Service users the inspector spoke to said that the proprietor is very approachable and friendly and listens to their views and wishes. The home was awarded the ISO 9001-2000 in August 2001. This is a quality assurance awarded to the home by an independent organisation. This was reviewed by the awarding company in April 2004.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 31 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? Service users are encouraged to deal with their own finances. In most instances, fees are paid to the home by direct debit. Where the proprietor of the home deals with the residents finances, appropriate records are kept. These were checked and found to be accurate and current. One service user the inspector spoke to said that she goes to the post office each week to cash her pension.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 32 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Across The BayPage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureAcross The BayPage 34 Public reports It should be noted that all CSCI inspection reports are public documents.Across The BayPage 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 12th May 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments and an action plan are available at the area officeAcross The BayPage 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 15th June 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Across The BayPage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Across The Bay confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Across The Bay am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Across The BayPage 38 - 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. 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