Inspection on 10/10/07 for Beach House

This inspection was carried out on 10th October 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beach House 06/08/08

Beach House 13/02/07

Beach House 10/03/06

Beach House 07/08/05

Beach House 15/03/05

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Beach House 322 Padiham Road Burnley Lancashire BB12 6ST Lead Inspector Mr Jeff Pearson Unannounced Inspection 10th & 11 October 2007 09:30 th Beach House DS0000061294.V347637.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 Beach House DS0000061294.V347637.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. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beach House Address 322 Padiham Road Burnley Lancashire BB12 6ST 01282 429657 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) Mr Alfonce Zindoga Mrs Concillia Tambudzai Zindoga Mrs Concillia Tambudzai Zindoga Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The registered person shall ensure that a suitably qualified and experienced manager who is registered with the Commission be employed in the home. The registered person shall ensure that staffing levels in the home remain at the same level as required by the Commission for Social Care Inspection The home is registered to provide personal care and accommodation for six people with a learning disability. Date of last inspection Brief Description of the Service: Beach House is a large garden fronted terraced house, situated within a short walking distance to Burnley Town centre, the property is in keeping with the neighbourhood. The accommodation available is homely and domestic in style. There is a lounge, lounge/dining room, house bathroom, kitchen and laundry room. The home accommodates six people in four single and one double bedroom. Most of the bedrooms have en suite facilities. Mr and Mrs Zindoga own the home and Mrs Zindoga is the registered manager. Staff are on duty to provide support 24 hours per day. Weekly charges for personal care and accommodation range between £450 and £600 depending on the level of support required. Residents are responsible for additional extras such as hairdressing, toiletries, and transport. Written information about Beach House, including the service users’ guide, statement of purpose and last inspection reports were available in the home. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Beach House on the 10th October 2007. The visit took 11½ hours and was carried out over two days by one inspector. Prior to the site visit, the registered manager was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures in the home. The residents and their relatives were invited to complete surveys, to tell the Commission what they think about the care service provide at Beach House. The files/records of two people using the service were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living at the home. Discussion took place with the residents, manager and staff. Various documents, including policies, procedures and records were looked at. Some of the accommodation and facilities were viewed. At the time of this inspection visit there were 5 people living in the home. What the service does well: This home is keen to provide and develop good quality support for current and future people using the service. Before people moved into the home, arrangements were made find out about their needs and wishes and they were invited to visit for a meal. One person explained “I came to look round before moving in, I stayed for tea” People were getting out and about in the local area and were being supported to gain new skills. Residents said, “I go shopping each week, we have our own carer to look after us” and “we get out and about” People living at Beach House were being given a lot of support to stay in touch with families and friends. “I go into town with a friend” and “My dad visits now and again and I go out to my sisters for tea” said two people. Help with personal needs was being given with care and people were being treated with respect. People were being enabled to make their own choices and decisions and be in control of their lives, they were encouraged to be independent. One person Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 6 commented “ I help out with the cooking, I clean and tidy my own room, its something to do and gives me a bit of responsibility” To make sure they knew what to do, staff were being given training when they started work in the home. People were being encouraged to say what they thought about the service and to make complaints if they wanted to. The staff did a good job and were liked by the residents “All the staff are fine, Ive really come on in the past few months,” said one person. What has improved since the last inspection? What they could do better: Improvements were needed with medication, to make sure people get their medication safely and at the right time. To make sure all medication matters stay safe and proper; they should be regularly checked. To make sure managers and staff do the right thing to make sure people are properly protected, the instructions for dealing abuse matters and reporting bad practice needed changing. The manager needs to ensure staff are recruited properly with all checks being carried out, as this protects people using the service. Individual care plans needed to include details of all needs and goals and how they are to be met, to ensure staff know exactly what to do for each person. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 8 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 Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The admission process ensured peoples’ needs and aspirations were known and planned, for before they moved into the home. EVIDENCE: Social services assessments seen on service user file case tracked along with homes own assessment, which was based upon the National Minimum Standards. The assessment process considered, matters such as mental health, communication, social, health needs and relationships. Peoples’ personal history had been noted, which helped ensure they responded to as a whole person. Records showed other people had been involved with the admission process, including Social Services staff and relatives. Risk matters had been identified and considered. The manager said the admission process was used to gather information to develop an appropriate plan of care to respond to peoples needs. Trial periods were being encouraged, records and discussion showed one person had visited the home on two occasions, before moving in “I came to Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 10 look round before moving in, I stayed for tea” explained one person. The AQAA (Annual Quality Assurance Assessment) completed by the manager stated, that when a placement is being considered, the home makes sure that everyone, both residents and staff feel that the person is suitable for Beach House and that they will fit in. The manager said all residents now had contracts in place these had been updated as recommended, contracts were seen on two peoples files. The AQAA indicated contracts include more information about the home including any restrictions and expectations of the resident and the home. The homes guide had been reviewed and updated; a copy was seen to be available in the homes kitchen. People spoken with didn’t remember seeing the guide. It was advised, that in future the guide could be reviewed with the involvement of the residents as an activity. It was suggested the guide include pictorial references, which may be helpful for some people with a learning disability. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all aspects of care planning were effective in ensuring people’s needs and aspirations are properly responded to. EVIDENCE: Residents spoken with were aware of their individual plans, “Its all written down” said one person. It was apparent the residents had signed in agreement with their plans and had been involved with the reviews. Evidence was seen of review meetings with families and Social Workers. The manager said the care plans were currently being reviewed to be more person centred. Advice had been sought and action taken, to change the care plan format in line with current good practice. It was apparent work was on going in this area, as the plans seen were half updated. It was apparent, some support needs and goal Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 12 planning were not properly reflected in care plans. Daily care notes included some inappropriate comments, which could be misleading and disrespectful. Care plans and care planning was discussed at length with the manager, in terms of person centred approaches and ensuring appropriate individual support needs are identified and responded to, monitored and reviewed as part of the care planning process. People livening at Beach House were observed to be involved in activities of daily living; for example, they were consulted about day to day matters such as trips out to the shops, meals, TV programmes, activities and other matters which affected them. The care planning process helped ensure their individual needs and wishes were known and planned for and residents meetings provided opportunity for group choices and decisions to be made. The notes seen of the resident’s meetings; showed various topics had been discussed including menus, social activities, and general routines. Residents completing surveys indicated they made decisions about they did each day. Discussion with residents and staff and observation of support practices showed people were being enabled to take risks to support independent living and skill development. Although the risk assessments included satisfactory details, two residents were occasionally staying in the home alone for short periods, particularly if they did not want join in with group outings, such as shopping. There were no risk assessment in place in relation to this activity. Risk assessments were discussed at length with the registered manager. In particular, ensuring all aspects of safety are fully considered and balanced with promoting independence and choice. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People were being supported to develop skills, by engaging in activities and accessing community resources. Positive relationships were being encouraged. EVIDENCE: The residents spoke of the various activities they were involved with in the community, including colleges and day centres, for computer skills and English. People were also being supported to pursue leisure interests such as, shopping, cinemas, football matches, pubs and clubs. One resident worked part time delivering newspapers. Two people were attending Church on a regular basis. The residents said they were looking forward to their forthcoming holiday in Blackpool. There were various activities and games available in the home, which were appreciated by the residents. An activities Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 14 timetable was seen, this indicated each persons’ planned activities, record seen of activities undertaken. The deputy manager said, day centres in the area had been visited to see what was on offer and various new activities were being considered, one resident had suggested horse riding. It was advised the residents be supported to put together a folder of the various resources available. Surveys completed by the residents indicated they could do what they wanted during the day, in the evenings and at weekends. Each persons’ activity programme influenced some daily routines. Residents said they usually got up fairly soon on weekdays, as they had things to do, but they usually had a lay in at weekends. They had locks on their bedroom doors and they had been given keys. The type of locks fitted meant the doors were always, locked, which limited choice; alternative locks were discussed with the manager. The residents shared some responsibilities for household chores such as cleaning their rooms and communal areas; the tasks had been agreed with them, those spoken with were happy to be involved with domestic chores. Ways of involving people with every day matters as an activity and opportunity for skill development; was discussed at length with the manager and deputy manager. Residents spoken with said they were keeping in touch with friends and families. Visiting arrangements were highlighted in the homes guide. Relatives completing surveys indicated they could telephone and visit the home at anytime. One wrote of the good support provided for regular visits to family homes. The residents spoken with were happy with the variety and quality of the meals, some helped with shopping and with the preparing of their own meals. A four-week menu system was in place. Staff said the menus had recently been reviewed with the residents; each person had a favourite meal included. The record of meals served did not include all food taken, it was advised further details be noted to ensure better monitoring and assist with future menu planning. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Most health and personal care practices and procedures were effective in ensuring people’s needs are properly and safely met. EVIDENCE: The residents currently living in the home needed minimal support with personal care needs, it was apparent people were being supported to choose their own clothing and take an interest in their appearance. A system had recently been introduced to promote more appropriate personal hygiene practices. It was advised that responding to such matters should be more appropriately reflected within individual care plans and daily records. The residents spoken with said they were having contact with their GPs when needed. Support was being provided for health care appointments. One relative survey included comments of appreciation for the support provided with hospital treatment and changes in medication. The manager and deputy Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 16 said on going routine appointments were being arranged in response to individual needs; a system was in place to enable regular health checks to be carried out. Some health care matters needed to be more effectively included in the care planning process. Medication policies and procedures were seen in the home. Medication information leaflets, in relation to prescribed items were available. The contracted Pharmacist had made regular visits to check systems and storage. The manager said most staff had undertaken medication management training. Records showed the residents had given consent for staff to manage their medication. Good practice matters in relation to people safely managing their own medication; were discussed with the registered manager. Individual protocols were in place for people prescribed ‘when necessary medication’, however, it was advised further details be noted to provide clearer directions for staff. There were some discrepancies in the MAR (medication administration record) looked at. For example, one label had differing dosage instructions on the MAR sheet to those on the item label; therefore staff had unclear instructions. One item did not have a label on the actual bottle. MAR sheet showed medication was being checked in, but these discrepancies indicated further attention was needed to ensure safer practices. The manager said an audit of medication practices was being carried out every two months; it was advised the tool for this be further developed to ensure a more thorough check. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate 22,23 This judgement has been made using available evidence including a visit to this service. Not all policies and procedures were effective in supporting the complaints process, or promoting the protection of the people using the service. EVIDENCE: The residents spoken with said they didn’t have any complaints, but they were aware of how to make a complaint. They felt residents meetings provided opportunity for people to voice opinions and raise minor issues. One relative wrote “I would feel confident and comfortable to contact the manager and take a complaint forward if I had one” The complaints procedure was seen on display in the homes kitchen, it included appropriate details and contact information, it was not particularly ‘user friendly’, for example, there were no pictures or illustrations which may be helpful for some people with a learning disability. It was therefore advised the procedure be reviewed and discussed with the residents. There had been no complaints made for over a year. Dealing and responding to complaints was discussed with the manager. It was suggested a suitable recording format be introduced, to ensure complaints are properly dealt with. Records being kept of the issues raised, investigations, interviews, strategies Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 18 and outcomes. This should show peoples views are properly listened to and acted upon. Since the last inspection, most staff had received POVA (Protection Of Vulnerable Adults) and managing aggressive behaviour training, arrangements were to be made for two new staff to attend this training. The manager and deputy manager expressed an understanding of protection matters and referral procedures. Not all the homes policies and procedures in relation to safeguarding people were available at the home at the time of the inspection visit. The Protection Of Vulnerable Adults policy and staff Whistle Blowing policy were later forwarded to the Commission. Both documents included some relevant information, such as descriptors of abuse and various safeguards. However, there was some inappropriate guidance in relation to investigating, consent issues, and taking referrals. The Vulnerable Adults procedure did not provide set step guidance on making referrals to the appropriate agencies and specific contact details, such as Social Services an the Police had not been included. The Whistle Blowing procedure did not include specific referral details for the Commission or Social Services. This meant suspicions, allegations and incidents of abuse or neglect, may not be properly dealt with for the safety and protection of the residents. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Improvements were ongoing to provide a more pleasant and homely environment for the people living at Beach House. EVIDENCE: The residents explained some of the changes made at the home, including the flowers tubs and painted gate and railings to the front of the home. Several new items of furniture had been provided, including a dining table, cabinets and some carpets had been replaced. The lounge and dining room provided comfortable and homely accommodation for the residents. Systems were in place to identify and respond to matters needing attention, the residents pointed out some minor matters, which were discussed with the manager. The residents liked their bedrooms and said they had everything they needed. Their rooms were personalised with their own possessions such as televisions, pictures, books and photographs. It was suggested that keyworkers (staff who Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 20 work more closely with residents) provide support with personalising and considering improvements in each persons room. Some bedrooms still needed redecorating and upgrading as paintwork, wallpaper, and carpets were showing signs of wear and tear. However, parts of the home were in the process of being decorated and the manager had identified further plans for ongoing improvements in the AQAA (Annual Quality Assurance Assessment) The home was found to be clean. Liquid soap dispensers and paper towels were provided in the bathroom, kitchen and staff toilet. Staff had cleaning schedules and task list to help make sure all parts of the home is kept clean. The laundry provided satisfactory facilities. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Recruitment practices and procedures were not thorough enough to ensure that residents are being properly protected. EVIDENCE: Positive interactions were observed between the residents and staff. People spoken with were generally appreciative of the support provided by the staff team. Staffing rotas were being devised to take into account the needs and routines of the residents. The manager said two residents had had recently taken part in the interview process. The records of the most recently recruited staff were looked at. Not all checks as required by the regulations to protect the residents had been carried out. For example, written references had not been obtained, gaps in employment had not been pursued, explained and recorded, one applicant had not completed the statement in relation to criminal offences. The manager Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 22 took steps to rectify these matters by the second inspection visit, by chasing up written references and requesting further details on application forms. Induction training records were seen to have been completed in relation to one person. However, one checklist seen was signed by staff but not by the person providing the training, therefore this did not provide an accountable indication that training had been given. The manager agreed to take action in respect of this matter. It was advised supervisory arrangements for new staff be recorded as part of induction training programme. The AQAA showed 95 staff have attained NVQ 2 or above, the deputy manager had just completed NVQ 4. Individual staff training records in the process of being developed, some certificates were seen to be available. Arrangements had been made for staff to be supervised on a one to one basis and plans were being made to ensure this practice continues. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Management and administration practices were effective in ensuring the home is run for the benefit of the residents, staff and visitors. EVIDENCE: The residents and staff spoken with expressed satisfaction with the management of the home; this was also reflected in the surveys completed by relatives. Mrs Zindoga, manager, had completed the Registered Managers Award and was a registered Mental Health Nurse. She had continued to develop her skills by attending relevant training courses and seminars, such as Protection Of Vulnerable Adults and food hygiene training. Mrs Zindoga was Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 24 working in the home for 20-25 hours per week, that the Commission expects the manager to be in day-to-day charge of the home was brought to her attention. Although this inspection showed several matters were in need of management attention, the Commission was satisfied from the managers’ proactive response to the inspection process and the plans in place to develop the home; that improvements will continue to be made at Beach House. To promote access to information and communication, it would be useful if Internet access were available at the home. Beach House had attained the Investors In People Award. Satisfaction surveys had recently been distributed to the residents and their relatives. It was advised the information from surveys be collated in the AQAA (annual quality assurance assessment) Records were seen of monthly maintence, also repairs carried out. Health and safety risk assessments were in the process of being completed. Discussion took place with the manager regarding accessing health and safety risk assessment training. It was advised a food safety policy be devised and introduced. The Department of Health guide ‘Essential Steps’ should be used to assess current infection control management. Arrangements were in place for all staff to receive training in all safe working practice subjects. The homes AQAA completed by the manager indicated the servicing and checking of equipment and installations, fire drills had been carried out. Health and safety policies and procedures were in place. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X 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 2 X 3 X 3 X X 3 X Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA9 Regulation 13(4)(b) Requirement Timescale for action 30/11/07 2. YA20 3. YA34 To ensure people using the service are as safe as possible, action must be taken to ensure all risks are properly considered and planned for, when promoting independence skills. 13(2) To make sure people using the 30/11/07 service are properly supported with their medication, action must be taken to ensure appropriate dosage instructions are on all prescribed items and in recording systems. 17, 18, 19 To protect people using the 30/11/07 schedule service, all required checks on 2 new members of staff must be carried out, with records kept, prior to them commencing duty. Timescale of 14/03/07 not met RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Beach House Refer to Good Practice Recommendations DS0000061294.V347637.R01.S.doc Version 5.2 Page 27 Standard YA6 1 YA6 2 YA20 3 YA20 4 YA20 5 YA23 6 YA23 7 To ensure people using the service receive appropriate person centred support and care, all needs and skill development should be identified, agreed and planned for in their individual care plans. To promote dignity, confidentiality and respect of people using the service, staff should be given clear guidance on appropriate recording in care notes. Residents should also be given the opportunity to read and contribute to their own records as appropriate. To show proper consideration has been given to promoting independence, each person’s ability to manage their own medication should be considered as part of a risk assessment process. To ensure people using the service receive their medication at the right time. Individual protocols should be written to provide clear detailed and agreed instructions for staff, on when to give ‘when required’ medication. To ensure management of medication is safe and appropriate, the auditing system should include a more thorough check of all aspects, including records, storage and administration. To protect people using the service, the protection of vulnerable adults procedure should be revised and up dated to more appropriate guidelines in line with current best practice. The referral procedure should provide clear, step by staff guidelines for staff to follow when reporting incidents allegations and suspicions of abuse or neglect, The procedure should include clear contact details, including telephone numbers of the agencies to which referrals are to be made. To protect people using the service, the staff whistle blowing procedure should include clear contact details, including telephone numbers, of agencies where bad practice can be reported, such as the Commission for Social Care Inspection and Social Services. Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Beach House DS0000061294.V347637.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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