This inspection was carried out on 4th October 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.
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 4th October 2005 10:00 Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 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.V257475.R01.S.doc Version 5.0 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.V257475.R01.S.doc Version 5.0 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(s)/company (if applicable) Name of registered manager (if applicable) 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.V257475.R01.S.doc Version 5.0 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 23.05.05 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. 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.V257475.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The manager was on annual leave when the unannounced inspection took place. The senior care staff at the home assisted with the inspection that consisted of; a tour of the home, talking with staff and residents, observing the care given and reading of documents. Not all the residents were seen as they were out of the home. Of the residents in the home four were spoken to along with all the staff on duty. There were no visitors to the home that could give their views of the service. A thank you is extended to the staff and service users who took part in the inspection and for their help and hospitality. What the service does well: What has improved since the last inspection? What they could do better:
There are still other areas of the home that need improvement and maintenance. These include the ceiling in the sitting and dining room and an upstairs bathroom. Improvements in these areas would make the home safer and more comfortable to the residents. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 6 Some of the documentation of care for new residents was not fully completed. This includes completion of the home’s assessment forms and the development of care plans and risk assessments. Gaining this information is important so that staff know how to care for each resident individually. Also the keys to the residents’ medicines are not handled in the safest way. This is because all the keys to the home are held together, which could give workers that are not qualified to give medicines access to them. 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.V257475.R01.S.doc Version 5.0 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.V257475.R01.S.doc Version 5.0 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): 2 and 4 The introduction process is well managed however the documentation of care plans and risk assessments for new residents was not completed. EVIDENCE: A new resident confirmed that they had introductory visits to the home. The home also had good supporting information from other professionals that gave a good history of the risk factors and care previously provided. However the home had not completed their care plan based on their initial assessment, as both of these were found incomplete. Staff were working on these plans however on the day of inspection this documentation was not complete. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 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): 7 and 10 Staff are aware of confidentiality issues and help residents make their own decisions about their lifestyle. EVIDENCE: It was observed that records were kept secure in the home and staff were aware of confidentiality issues. Residents confirmed that they have the choice of when they want to go to bed and get up. Also it was observed that they have the freedom to come and go from the home as they choose. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 10 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): 13 and 16 Staff respect the residents’ rights and residents are able to use public services when they choose. EVIDENCE: The residents of the home use local services for example the local shops. They also use the local transport system on a daily basis. Staff were observed to address the residents in a kind and friendly way and residents confirmed that staff treated them well. When residents have their own post they confirmed that it is given straight to them and not opened first by staff. Residents choose if they want their bedrooms locked or the door left open and staff were observed to knock before entering a resident’s room. Residents spoken with were happy with their rooms. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 11 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 and 20 The home delivers personal support that maintains the privacy and independence of the residents. One aspect of the safekeeping of medication does not follow current guidelines. EVIDENCE: Residents now have their pictures held on the medicine folder for the purpose of identification and to ensure safe administration. All the keys for the home including the medicine keys are kept together on the same bunch. This is not the correct practice as set out in the Royal Pharmaceutical Guidance for the Administration and Control of Medicines in Care Homes. Residents confirmed that personal support is delivered to them in the privacy of their own room and staff will offer help with personal hygiene as needed. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 12 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): 23 Satisfactory procedures are in place for the protection of the residents. EVIDENCE: Staff were aware of the Southend-on-Sea adult protection policy and had received training on this topic. One of the residents spoken with confirmed that the home help her manage her money and that she is happy for them to do that with her. The residents’ money is kept in a secure place and is regularly checked by home staff to ensure that there is no mismanagement of this money. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 13 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 The home was clean however some areas needed upgrading and maintaining to provide a safe and comfortable environment. EVIDENCE: Some of the panels on the suspended ceiling in the dining room and sitting area were becoming detached from there fixing. The upstairs bathroom was looking tired and worn and in need of upgrading. This bathroom also had no warning signs for the hot water. Temperatures of 49 degrees Celsius were recorded in this bathroom. The Commission for Social Care Inspection recommends 43 degrees Celsius. The home was clean warm and comfortable and the residents spoken to were happy with their surroundings. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 14 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): The home has a good trained staff team EVIDENCE: Staff were observed to have a good attitude towards the residents and the residents said that staff treated them kindly. Staff had a good knowledge of the residents’ day-to-day care and of the other professionals that visit the home for example, the community psychiatric nurses role. The staff are continuing with the NVQ training as well as topics discussed in the home. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 15 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 The home manages the health and welfare of the residents well, however hot water temperatures are still high in one communal area of the home. EVIDENCE: As the registered manager was on leave at this inspection it is unclear if the NVQ 4 has been commenced. However the home is still generally well managed. The hot water temperature in the upstairs bathroom was still high as described in standard 24 and there were no warning signs for residents to be aware of this. The fire door at the top of the stairs was also wedged open with a tissue. There was no evidence found to indicate that this was risk assessed as safe practice. Although this year is not completed yet, there was only evidence of last years (2004) quality assurance surveys. As yet no surveys were seen that recorded the residents or others views of the home for this year (2005). Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 x 3 x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x x 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x x x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bali Hai Residential Care Home Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x DS0000015419.V257475.R01.S.doc Version 5.0 Page 17 yes 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 YA2 Regulation 15 Requirement The Registered Person must ensure that assessment documentation is completed for new residents. The Registered Person must ensure that medicine keys are kept according to The Royal Pharmaceutical Guidance for The Administration and Control of Medicines in Care Homes. The Registered Person must ensure that the damaged ceiling in the sitting / dining area is repaired The Registered Person must ensure that hot water temperatures are maintained at a suitable temperature. Timescale of 18/07/05 not met. Timescale for action 05/12/05 2 YA20 13(2) 04/10/05 3 YA24 23(2)(b) 05/12/05 4 YA42 13(4)(b) 05/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
DS0000015419.V257475.R01.S.doc Version 5.0 Page 18 Bali Hai Residential Care Home 1 2 3 4 Standard YA24 YA39 YA42 YA42 For the comfort of the residents the upstairs yellow bathroom should be upgraded The home should submit the quality assurance report for this year to the Commission for Social Care Inspection once completed. The Registered Person should evidence that the Gas safety certificate has been issued. The home should have written evidence of when it is assessed as safe for fire doors to be wedged open. Bali Hai Residential Care Home DS0000015419.V257475.R01.S.doc Version 5.0 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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