Inspection on 19/09/02 for Across The Bay

Care Home For Older PeopleAcross The Bay479 Marine Road Morecambe Lancashire LA4 6AFAnnounced Inspection19th September 2002 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/AGENCY INFORMATION Name of establishment/agency 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 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 14th March 1990 Conditions Apply ? Annex for 16 and 17 year olds plus Part VI Care Home Regulations ­ Children, apply? Date of last inspectionDate latest registration certificate 30th July 2002 If Yes Refer to Part CDate and Time of Inspection Visit Name of Inspector(s) Name of Lay Assessors (if applicable) Name of Interpreter/Signer (if applicable)19th September 2002 ­10 am Ajam AuckburallyID CodeAcross The BayPage 1 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection 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: Part E: E.1. E.2. Compliance with Conditions of Registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Action Plan AgreementAcross The BayPage 2 INTRODUCTION TO REPORT AND INSPECTION Every establishment/agency which falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment/Agency is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 and / or the Children Act 1989 as amended. This document summarises the inspection findings of the NCSC 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 NCSC 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 · Report of the lay assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections will be 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 and the Children Act 1989 as amended. The report is based on the findings of the specified inspection dates.Across The BayPage 3 BRIEF DESCRIPTION OF THE SERVICES PROVIDED Across The Bay is a home for Older People. It is situated facing the promenade in Morecambe and close to Happy Mount Park. The home can accommodate a maximum of 24 residents of both sexes The home is staffed around the clock to care for the residents. Facilities at the home include a large comfortable 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. .Across The BayPage 4 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.)This service has been inspected for the first time against National Minimum Standards introduced form 1st April 2002. As a result, this report may contain a substantial number of recommendations and requirements. If so, the number of these should fall significantly at the next inspection when the provider will have had the time to take account of the new legislation and standards and to take action to meet them. Any breaches in standards which pose a more immediate risk to customers of services have been highlighted for urgent action. Choice of Home: A statement of purpose has been produced and a service user guide is in the process of development. 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. Health and Personal Care: Care plans defining how the needs of service users are being met are in place. Policies are in place for self medication. 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. Daily Life and Social Activities: Service users were positive about the social life within the home, however the scope of activity and diversion could be improved by encouraging them to follow previous hobbies and interests where appropriate. Arrangements in place for access to spiritual leaders appeared to be satisfactory. Complaints: A procedure for the recording of complaints was in place. The home has received none since the last inspection. Policies in respect of the protection of adults and whistle blowing were in place. Environment: Most of the bedrooms meet the minimum size requirements and communal space falls short for the number of service users the home is currently registered for. The home appeared clean and hygienic. Staffing: 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. Management: The proprietor has many years experience of running a care home and has completed the care component of NVQ level 4 and is near completion of the management component. 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. There were 19 service users in the home during the inspection and they all said that they are well cared for and that all the staff are kind and helpful.Across The BayPage 6 Requirements from last Inspection fully actioned? If No please list below STATUTORY REQUIREMENTSYESIdentified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionNo.Refer to StandardGood Practice RecommendationsActioned Yes/NoAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. CONDITIONS OF REGISTRATION Met (Yes / No)Across The BayPage 7 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 and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan is shown in Part E of this report. 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, the National Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The heating, lighting, water supply and ventilation of service users accommodation must meet the relevant environmental health April 2003 and safety requirements and the needs of individual service users. The registered person must produce a written guide to the care home (in these Regulations April 2003 referred to as the service user guide) The home must provide sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding April 2007 corridors and entrance hall amounting to at least 4.1 sq m for each service user. ( To be applied from April 2007). Single rooms in current use must have at least 10 sq m and double rooms have at least April 2007 16 sq m from April 2007 The home must provide private accommodation for each service user which April 2003 is furnished and equipped to assure comfort and privacy. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) by 2005. The registered manager must have at least 2 years experience in a senior management capacity in the managing of a relevant care setting within the past 5 years; and by 2005 2005123OP2525OP1323.2(e)OP20423(f)OP23516.2 (c)OP24618OP2879OP312005Across The BayPage 8 has a qualification, at level 4 NVQ, in management and care or equivalent. 8 25 OP34 There is a business and financial plan for the home, must be open to inspection and reviewed annually. April 2003RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Recommendation Action Timescale Standard * for action 1 36.2 Care staff should receive formal supervision at least 6 times a year* 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 9 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 Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading 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 NO YES NO YES 19/11/02 10:00 AM 10The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Childrens Homes have been met. 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) Zero 0 in the Standard met? box denotes standard not assessed on this occasion.Across The BayPage 10 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 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 ad facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. Range of fees charged From (£) 260 To (£) 297Any charges for extras Key findings/EvidenceYESPERSONAL ITEMS HAIRDRESSINGPRIVATECHIROPODY 2 Standard met?The home has produced a statement of purpose which gives details of the services and facilities available at the home. This is available to staff and relatives and service users. The staff on duty said that they were aware of the statement of purpose and although not fully conversant with all the details, they were aware of its general composition. A service user guide needs to be produced and the proprietor said that this will be done soon. 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). 3 Key findings/Evidence Standard met? Contracts are issued to all service users or their representatives. A copy of the contract is kept in the personal file of the service users. The proprietor said that he reads through and explains the contents of the contract to service users and their families. A copy of the contract was examined and found to be current and up to date.Across The BayPage 11 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? Assessments are carried out by the proprietor or senior care staff who will visit service users in their own homes or in hospital where appropriate. Assessment form is comprehensive and lists all areas of care. Once completed, the assessment will give the reader a good understanding of the needs of the service users and how they are being met. Completed assessments forms were seen and found to be filled in accurately and fully. They are kept securely in a filing cabinet in the office and are accessible to the staff. 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?Evidence was found in care plans that specialist services are accessed to meet the assessed needs. E.g. district nurses, continence advisors. The inspector was informed that service users with specialist needs are only admitted to the home if management feel their assessed needs can be met by the facilities and services available.Standard 5 (5.1 ­ 5.3) The registered person ensures that the 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? It is clearly stated in the statement of purpose that clients interested in coming to Across the Bay are encouraged to visit and sample the atmosphere and level of service. This gives the prospective service user time to get to know the staff and adjust to new people and surroundings. A months trial period is always given before taking permanent residency. Some of the service users said that they were given the opportunity to visit prior to admission whilst the majority said that their families visited on their behalves. 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. 0 Key findings/Evidence Standard met? The home does not provide this service.Across The BayPage 12 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 health care needs are Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines are fully met. · 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? A service user plan is generated from the detailed assessment carried out for all the service users. These contain details of areas where intervention by staff is required to meet the assessed needs. They are reviewed and updated by the staff monthly. Service users and their representatives can be involved in these reviews. A sample of care assessments were examined and found to be accurate and current.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 service users admitted to A & E since last inspection No. of service users with pressure sores (from information taken from care notes) Key findings/Evidence 5 0 Standard met? 3The accident book was checked and found to be current and accurate. If any service user develops pressure sores, the district nurse will be involved for treatment and advice. Service users can retain their GPs and other health professionals. If a change is required, then assistance is given by the staff of the home.Across The BayPage 13 Standard 9 (9.1 ­ 9.11) The registered person ensures that there us a policy and staff adhere to the procedures for the receipt of 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. 3 Key findings/Evidence Standard Met?The home has a comprehensive medication policy in place which staff are made aware of during their induction period. Only staff who are named as competent and trained to administer medication do so. Service users have the opportunity to self medicate, following a risk assessment, but must sign a disclaimer if this is their choice to do so. Records showed that any change in medication was fully noted, along with GP communication. The home also has a Controlled Drugs Policy in place, although none are used at the present time.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, consultation with and examination & by health & social care professionals, consultation with legal & financial advisors, maintaining social contacts with relatives & friends, entering bedrooms, toilets & bathrooms, following death. 3 Key findings/Evidence Standard met? There is a clear policy on respecting service users privacy and to treat them with dignity. This is contained in the statement of purpose. The service users said that staff always knock on their doors before entering their rooms. The proprietor said that the service users can use the office phone if privacy is required. The service users said that they prefer to be called by their fist names as it is more friendly. They are given the choice how they wish to addressed. Service users can use their own rooms if they need privacy for any purpose. 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. 3 Key findings/Evidence Standard met? The written policy on the care of the dying is clear and defines the procedure of dealing with death and the dying. Some of the staff have attended a training course on the subject. Care plans refer to people wishes at the time of their death.Across The BayPage 14 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?Through observation and discussion with service users and staff the inspector gathered evidence to show that routines were flexible and the needs of service users given priority. Service users past interests and hobbies are recorded on their files, and they are encouraged to continue with these if feasible. Meal times can be flexible and a choice of food is always available, with service users suggestions welcomed. Observation of the homes planned menu and sampling of a meal confirmed a balanced diet is being provided.Standard 13 (13.1 ­ 13.6) Service users are able to maintain contact with family/friends/representatives and the local community as they wish. 3 Key findings/Evidence Standard met?Free text box up to ten linesVisiting is open and the proprietor said that visitors are always made welcome. Refreshments are usually provided. Priest and other religious figures visit the home on a regular basis. The proprietor said that if service users need a specific vicar or priest, then he would try and arrange a visit from that person. The proprietor said where possible he will ask families of service users to accompany them to hospital appointments and other appointments. If they are not able to do so, then either himself or a member of staff will escort the service user.Across The BayPage 15 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? Service users are encouraged to manage their own finances if they can. Where the home manages the finances of service users, appropriate records are maintained. These were checked and found to be accurate and current. Service users can bring as many of their own possessions to the home as the room they occupy will allow. Some of the service user have personalised their rooms with their own furniture and other belongings. They said that it is nice to be surrounded by ones own things. 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 congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users said that the food served is good and that they get plenty to eat. An alternative is provided at lunch time if service user does not like what is on offer. A wide selection of food is provided for breakfast including a cooked breakfast. Similarly service users can choose from a good selection of food for tea time. . Meals are served in the dining room which is situated on the lower floor of the home. Service users can eat in their rooms if they want although they are encouraged to use the dining room as part of social interactions with the other service users.Across The BayPage 16 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 from last inspection No. of complaints fully substantiated No. of complaints partly substantiated No. of complaints not substantiated No. of complaints not yet resolved Percentage of complaints responded to within 28 days Key findings/Evidence 0 0 0 0 0 0 3Standard met?A clear and comprehensible complaint procedure has been produced by the home. It gives details oh how and who to complaint to including the contact for the National Care Standards Commission. A copy of the complaint procedure is included in the statement of purpose. Service users said that if they have any complaints, they will talk to the staff or the proprietor. The inspector explained to some of the service users the role of the National Care Standards Commission in relation to complaints and inspections. 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. 3 Key findings/Evidence Standard met? Service users said that as far they are aware all their rights are protected and maintained. A Charter of Rights is available in the policy and procedures manual of the home. All service users are on the electoral register and vote according to their wishes during an election. They can either vote by going to the polling station or by the use of postal votes.Across The BayPage 17 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 DOH Guidance No Secrets No. of staff referred for inclusion on POCA/POVA lists Key findings/Evidence Standard met? YES0 3There is a well defined policy and procedure on adult abuse and whistle blowing. This is available to all staff and is kept in the staff manual. The induction training for new staff includes this policy and procedure. Staff are required to sign a declaration to confirm that they have read and understood the policy.Across The BayPage 18 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 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. · Service users live in safe and 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 the Bare area of Morecambe and facing the sea front. The home is close to all the amenities but still not easily accessible by service users due to their poor mobility and general frailties. The home provides accommodation in mostly single rooms although some double bedrooms are available. The home has several floors and a passenger lift is available for access to all of them. Service users can use the lift independently if they are able and willing. Ramps and handrails are provided. The proprietor said that there is an on going programme of maintenance and decorating. Standard 20. (20.1 ­ 20.7) 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.m for each service user. (to be applied from 1st April 2007 for homes existing prior to 1st April 2002 which do not meet this standard). 1 Key findings/Evidence Standard met? This standard does not have to be met in full until April 2007, however this home has adequate communal space for 21 service users against the 24 it is registered for. The home has two large lounges on the ground floor and a dining room on the lower ground floor. Service users can use these facilities freely. Smoking is only allowed in the designated area.Across The BayPage 19 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? There are an adequate number of toilets and baths to meet the needs of all the service users. A Parker bath is available to help the service users have a bath with ease. There are also raised toilet seats and other aids to help service users retain their independence and maintain their dignity.. 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. 3 Key findings/Evidence Standard met? The premises are well maintained and the proprietor always ensure that any repair or maintenance is carried out as soon as possible. A call system is available for service users to summon assistance when required. A passenger lift is available to access all floors and service users can use it independently if they can or wish. The proprietor said that any other equipment to aid independence will be acquired as necessary and will be dependent upon service users assessments and the suitability of the home to install or fit such equipments.Across The BayPage 20 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Single rooms with at least 10 sq.m usable space Single rooms below 10 sq.m usable space Single rooms accommodating wheelchair users At least 12 sq.m Less than 12 sq.m Shared rooms at least 16 sq.m Shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Number of single bedrooms with en suite Number of single rooms without en suite Number of double rooms with en suite Number of double rooms without en suite Key findings/Evidence NO NO YES 1 13 2 3 Standard met? 1 8 6 0 0 0 3 2This standard does not have to be met in full until April 2007, however the proprietor said that he is planning to meet it fully by the stated date.Across The BayPage 21 Standard 24 (24.1 ­ 24.8) The home provides accommodation for each service user which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? All the bedrooms are adequately fitted and furnished. Curtains and blinds are provided. All the bedrooms have at least one easy chair and a small table. The proprietors said that if required, additional chairs and table can be provided as long as they do not affect the safety of the service users. Some of the bedrooms are quite small and will not be able to accommodate all the necessary furniture and fittings as recommended by this standard. 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 home is heated by a gas central heating system. The radiators will need to be fitted with low heat surface covers and individual thermostatically control valves in order that service users can control the heat. Hot water to the baths and hand wash basins is delivered at the recommended temperature of 43 degrees C. Standard 26 (26.1 ­ 26.9) The premises are kept clean and 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. 3 Key findings/Evidence Standard met? The home is kept clean and in good hygienic order. All laundry are washed on the premises and the laundry is situated away from food preparing area.Across The BayPage 22 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 and 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 Care No. service users High needs No. service users Medium needs No. service users Low needs No. of staff hours required No. of first level registered nurses Key findings/Evidence 0 9 11 0 0 Standard met? 0 No. staff hours allocated No. staff hours allocated No. staff hours allocated No. of staff hours provided 0 0 0 0 Nursing 0 0 0 0The above figures have been provided by the home, however the Department of Health staffing guidance does not have to be complied with until April 2003. The home was found to be staffed in accordance with previous local authority guidance and compliance.Across The BayPage 23 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of staff (NVWQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and in care homes providing nursing, excluding those members of 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 Key findings/Evidence 3 15 Standard met? 1This standard does not have to be met in full until April 2005, however the home has made a start in that 3 care staff have completed NVQ level 2 and several more staff are on the course at the presentStandard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? There is a thorough recruitment policy at the home. Applicants are required to nominate referees and undergo a police check and formal interview. This process confirms the integrity of the applicant and their suitability for the post they have applied for. Records are kept of all the recruitment documents and the inspector examined a number of staff records that confirmed that the process was followed. Duty staff confirmed that they underwent such a process prior to their appointments at the home. 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. 3 Key findings/Evidence Standard met? All new staff are given an induction training programme when they start work at Across the Bay. Further training, both internal and external is available to all staff. Some of the staff have completed their NVQ level 2 training. The inspector during discussion with duty staff was able to confirm this. Records of training were made and were available for inspection.Across The BayPage 24 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 responsibility fully. · Service users benefit from the ethos, leadership or 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 nearing completion in NVQ 4 management. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The management of the home has an open door policy and service users and staff can see the proprietor when they want. The staff said that they get on well with the management of the home and that they will listen and act upon any problem they may have. The inspector observed good interactions between the staff and the residents. The office is not too easily accessible for the residents to see the proprietor, but he said that he spends a lot of time in the home and if he is in the office, the staff can call him to come and see any resident who wish to see him. The proprietor said that he holds regular staff meetings although it is very difficult to get all the staff to attend. He said that he is contact with all the service users on a daily basis and listens and acts on their wishes and concerns.Across The BayPage 25 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 the success in meeting the aims and objectives and the statement of purpose of the home. 3 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 an informal basis and this is done by regular contact with them on a daily basis. 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. Advice was given to the home to introduce more formal monitoring such as service users questionnaire. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? The owner of the home said that business is in a healthy financial state and that an accountant is employed to do the accounts. No written evidence of this was seen, however the owner said that the home has been operating successfully for several years. 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 users. 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 Key findings/Evidence Standard met? 3 4 1 0Service 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.Across The BayPage 26 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. 2 Key findings/Evidence Standard met? Staff are offered regular supervision, but these are mostly informal. Advice was given to the management of the home to start formal supervision for all care staff at least six times a year.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. 3 Key findings/Evidence Standard met? Each service user has a personal case file containing all relevant information about them. These are kept securely in a locked filing cabinet and accessible only to the staff who need to use them for information. The service users or their representatives may see these files if they wish. Several records required by regulation were examined: Accident Book; Service users Case files; Staff Files; Fire Records and others. These were found to current and accurate.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. 3 Key findings/Evidence Standard met? Staff are trained in order that they can deliver care to the service users safely and at the same time work in a safe environment. The home has policies and procedures to ensure the safety of all its staff and those service users who live there.Across The BayPage 27 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceAcross The BayPage 28 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Lead Inspector Date Public reportsSignatureSignatureIt should be noted that all NCSC inspection reports are public documents.Across The BayPage 29 PART EPROVIDERS RESPONSEE.1Please provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed and a completion date within the stated timescale.STATUTORY REQUIREMENTS No. Regulation Standard Action being taken to address Requirements Providers comments and an action plan are available at the Area Office. Completion dateRECOMMENDATIONS No. Refer to Standard Action being taken to address Recommendations Providers comments and an action plan are available at the Area Office. Completion dateAcross The BayPage 30 E.2PROVIDERS AGREEMENTRegistered Person(s) 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 19th September 2002 and any factual inaccuracies: Registered Persons statement of agreement/comments: Please complete the relevant section that applies. E.2.1 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(s) and that I agree with the requirements made and will seek to comply with these. Or E.2.2 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(s) for the following reasons:Signed Designation Date Note: In instances 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 31 Across The Bay / 19th September 2002Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000009668.V15157.R01© This report may only be used in its entirety. 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