CARE HOME ADULTS 18-65
Bali Hai Residential Care Home 14/16 Southbourne Grove Chalkwell Park Westcliff On Sea Essex SS0 9UR Lead Inspector
Nicola Dowling Unannounced Inspection 22nd August 2006 10:00 Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bali Hai Residential Care Home Address 14/16 Southbourne Grove Chalkwell Park Westcliff On Sea Essex SS0 9UR 01702 479867 01702 479867 Telephone number Fax number Email address Provider Web address Name of registered provider Name of registered manager Type of registration No. of places registered (if applicable) Mrs Vijay Luxmi Rattan Mrs Vijay Luxmi Rattan Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. No more than 12 service users with a mental disorder, excluding learning disability or dementia, to be accommodated. The age of the service users will be between 18 and 65 years. Date of last inspection Brief Description of the Service: Bali Hai is a large domestic house providing care and accommodation for up to twelve residents in six single and three double rooms. There are two lounges available one of which incorporates a dining area. There is a small garden. The smoking room and laundry room are accessed through the garden. The cost of care at Bali Hai ranges from £279.47 - £650.00. Bali Hai is situated near Chalkwell Park and is close to all local amenities and services. The home is decorated, furnished and maintained to a satisfactory standard. There are no requirements for a passenger lift. Disabled access for visitors is limited to the ground floor. There is no allocated off road parking but this is normally easy to find in the immediate locality. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a six and a half hour period on one day. The inspection consisted of a tour of the home, talking with staff and residents, observing the care given and reading of documents. Most of the residents were seen and spoken to. Some residents were out at various day care centres. All the staff on duty were spoken to. The survey forms filled in by the residents also contributed to the report. The inspector would like to thank the staff and residents for their hospitality through the day. What the service does well: What has improved since the last inspection?
Since the last inspection there have been a number of improvements to the environment. The upstairs bathroom has been refitted. Some resident’s rooms have been redecorated and have new carpets. There are also new settees in the lounge and the ceiling has been repaired. The manager produced new documentation that is being started by the home. This is updated information for the benefit of the residents and prospective new residents and their families. Also there are new staff employment forms to make sure that those working in the home are safe to look after the
Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 6 residents. Access to the residents’ medicines is now secure. Medicine keys are now held separately from the house keys. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The introduction process to the home is well managed. Information about the home is being updated and will be presented in a picture format. EVIDENCE: Currently the home is revising the Statement of Purpose and Service User Guide. Information in these brochures is being updated and formatted with pictures. Once completed both these documents will be sent to the Commission for Social Care Inspection. Currently the home is full. Documentation was available regarding the needs assessment for the residents. Of the three files inspected the needs assessment had been completed. Seven residents responded to the survey form and all said that they had received enough information about the home before moving in. The manager or deputy manager undertake the initial assessments and residents confirmed that they are offered trial visits to the home. Each resident has a contract that they have signed. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The residents’ are looked after well and are supported by staff to take their own decisions. EVIDENCE: Of the three case files checked all had an up to date care plan that included a risk assessment that is regularly reviewed. Residents have one to one time with their key workers and residents commented that they knew their key worker, that they “liked the staff” and could “confide in” them and felt “supported” by them. Staff help residents to make decisions when needed, however independence is encouraged and residents make their own day-today decisions. For example; what to wear, when to catch the bus, going out for the day. The risk assessments accurately reflected the residents’ behaviour and staff know the residents well enough to be aware of behaviour that may cause an incident. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 10 Residents from different ethnic backgrounds reside at the home however none have special requirements. Information about the residents is held securely and staff are aware of confidentiality matters. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents have good food and a routine lifestyle that is active at this home. EVIDENCE: Residents confirmed that they went out most days in the week to various centres. The residents have bus passes and plan their own journeys to the activity centres or to appointments. The home has links with Rethink in Rochford and Canvey island, also activity centres in Southend. Within the home residents have their own routines and can spend time in their rooms or where they choose. Staff were respectful of the residents’ privacy. The residents go out on trips with staff for example shopping and they also have a holiday to look forward to. All residents liked the hot food that is cooked in the home. Some residents make cakes for others and commented how they liked this activity. The main meal is served in the evening with sandwiches or a snack at lunchtime. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Medication practices are good at this home. There is good support for residents with their physical and emotion care. EVIDENCE: During the inspection a district nurse visited the home and confirmed that residents have treatment in the privacy of their own room. From observation residents chose their own style of dress and they reported that they can go to bed and get up when they choose. The home has good links with the residents’ GP’s and the psychiatric services. There is a system in place to ensure residents keep appointments with health professionals. For some health appointments staff will go with the resident to provide support to them. Currently there are no residents that administer their own medication. Only staff that are trained to give the medication issue it to the residents and there have not been any reported incidents of medication errors at the home. The home have a recording system in place for administering medication safely. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: There has not been any protection of vulnerable adult investigations at this home. Staff have received training in this area and are aware of abuse issues and how to report it. The Commission for Social Care Inspection has not received any complaints about this home. Some residents have complained about each other. This has been dealt with to the satisfaction of the residents concerned and there is a detailed written record of the incidents. However no regulation 37 form was completed to inform the Commission for Social Care Inspection of this event. Residents commented on the professional attitude of staff when issues are raised and how quickly life gets back to normal with out any discrimination. Some areas of the complaints procedure need to be updated. This refers to the Commission for Social Care Inspection contact details. This was discussed with the manager who agreed to reword this policy. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable environment that is clean. EVIDENCE: The premises are safe comfortable airy and clean and meet the needs of the residents. There are no offensive odours and residents have access to all areas of the home. There is ongoing maintenance. Some areas of the home are worn however this does not detract from the homely atmosphere. The home is clean and the laundry area is maintained. Residents commented that they were happy with the way the laundry is carried out and the cleanliness of the home. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Friendly and trained staff look after residents at this home. EVIDENCE: There are two staff on duty through the day and one staff at night. The staff receive training in various topics and most staff have an NVQ in care at level 3. The deputy manager is undertaking the NVQ managers’ award. As well as external training the home offer in house training to. Staff spoken to were motivated and enthusiastic about their roles. Those on duty were observed to communicate well with the residents and the residents commented that the staff are friendly and approachable. The manager provides regular supervision for the staff and does an annual appraisal with staff. Staff confirmed that this took place. Two recruitment records were checked and all had the appropriate documentation in them. The manager reported that a new application form is to commence that is more detailed. There was documentary evidence that new staff receive induction training. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. This home is well managed and is run with the interest and safety of the residents in mind. EVIDENCE: The registered manager is the proprietor and has run the home for many years. The manager keeps up to date by regular training and works day to day in the home. A quality assurance report has been submitted to the Commission for Social Care Inspection with suggestions raised from this report. The homes safety certificates were checked and these were all up to date. These included gas safety, electric and portable appliance testing. There are weekly fire checks in the home. The manager is also updating and reviewing the homes policies. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 37 Requirement The Registered person must inform the Commission for Social Care Inspection under regulation 37 any event that adversely affects the well-being of a resident. The Registered person must reword the complaints procedure regarding contacting the Commission for Social Care Inspection Timescale for action 01/11/06 2 YA22 22 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA1 YA24 Good Practice Recommendations The updated version of the Service User Guide and the Statement of Purpose should be submitted to the Commission for Social Care Inspection. The Registered person must submit a plan for projected future maintenance of the home. Bali Hai Residential Care Home DS0000015419.V309626.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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