CARE HOME ADULTS 18-65
Beach House 322 Padiham Road Burnley Lancashire BB12 6ST Lead Inspector
Mrs Marie Dickinson Unannounced Inspection 13 & 20 February 2006 10:00
th th Beach House DS0000061294.V323140.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.V323140.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.V323140.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.V323140.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 proivde personal care and accommodation for six people with a learning disability. 10th March 2006 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, and is in keeping with the neighbourhood. Mr and Mrs Zindoga own the home and Mrs Zindoga is the registered manager. The home accommodates six people in four single and one double bedroom, most of which are en suite. There is a lounge, dining room, kitchen and laundry room, domestic in scale and appearance. Information about the service is available from the home for potential residents in a Statement of purpose and Service User Guide. 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. Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place on the 13th & 20th February 2007. The inspection involved getting information from staff records, care records and policies and procedures. It also involved talking to residents, staff on duty, the registered provider/manager, Mrs Zindoga. The inspection included a tour of the premises. Two questionnaire responses were returned to the Commission from residents and two from relatives/visitors who gave their personal view of the services provided. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Younger Adults. What the service does well:
Before people were admitted they were assessed to see if their needs can be met in the home. This assessment gave staff information they needed to make sure people were cared for properly. Staff worked to a key worker system that enabled residents to have personalised care, which according to residents and a relative, made a difference to making progress. To make sure residents keep safe, staff supported residents in responsible risk taking. Staff were required to read all risk assessments to make sure they knew what to do to help residents in various situations. Residents had the opportunity to make decisions about their lives. Staff helped them and took into account their wishes. They learned new skills and activities were varied and personal to them. Since the last inspection the residents had been on holiday which they ‘really enjoyed’. Visitors were made very welcome. Residents said they liked their bedrooms. Their rooms were personalised to their own taste and needs. Those residents who sent written comments to the Commission said the home was always fresh and clean. Sufficient staff were employed and were supervised daily in their work. Staff said they enjoyed their work. Training provided was good and they were trained in good care practice. Teamwork was evident and staff showed a commitment to good practice with residents’ welfare in mind. Residents said
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 6 the carers treated them well, ‘they are a good bunch now’, and ‘we get on well’. Confidence was expressed in how the home was managed. Residents and staff felt they had an influence in how the home was run as their views were listened to. What has improved since the last inspection? What they could do better:
People making enquiries about the home should be provided with an accurate picture of the type of home Beach House is, to help them decide if it is the type of home they want. People should be given a reasonable time period of three months to settle in before a decision is made to become a permanent resident. Also existing residents should be consulted about living with a new resident to make sure everyone is happy with the arrangement. All residents must also be supplied with a contract so they know about the terms and conditions of living in the home. The care plans must provide more detailed information for staff to help make sure residents’ needs are met in a consistent manner. Residents and staff need to know what their role and responsibilities are when meeting needs, so that everyone works together to achieve this. To make sure medication is safely managed two staff must sign handwritten additions to the medication record. Where medication prescribed to be given when necessary, the circumstances this would be given should be recorded. This will make sure staff follow instructions and give residents medication correctly. Because relatives who sent written comments to the Commission did not know the homes complaints procedure, this information should be better advertised. The home must be kept reasonably decorated inside and out and provide a homely environment for residents to enjoy.
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 7 Residents occupying the double bedroom should be given an opportunity to move to a single room when one becomes vacant. A decision to share a bedroom with a new resident should be a mutual consent. Improvements must be made to the collation of records when recruiting new staff to the home, this is to ensure that all staff have been appropriately vetted and are suitable to work with the residents. Because staff are sometimes expected to manage difficult situations they should be trained in managing aggression as part of induction. Staff should also be formally trained in Adult Protection and have regular formal supervision to support them in their work. To help residents understand how the home is managed in their interests a copy of relevant policies and procedures should be given to them in a format they can understand. They should also have copies of other documents such as contracts and house rules. 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.V323140.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.V323140.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): 1,2,4,5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents were provided with written information about the services and facilities at the home to help them decide whether they may wish to stay there. Not all residents had a copy of their contract which meant they were unaware of an official agreement outlining the terms and conditions of living in the home. Residents had their needs assessed which gave staff information to help look after them properly. EVIDENCE: A new service user guide was available for new people. Information included the terms and conditions of residency. Fees are not included, as this is individual according to resident’s needs and what is agreed by social services. The guide depicted as a modern house set in it’s own grounds and did not reflect the true design of the home. There had been three new admissions to the home. One service user had been admitted over the weekend as an emergency admission. The assessment
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 10 showed essential information was recorded to provide staff with sufficient knowledge about the service user’s circumstances and level of support required. Individual personal, social, and healthcare needs were identified. The assessments highlighted a number of complex mental health needs in addition to learning disability. Contracts were available to use, however they were not issued in three instances and had not been completed properly in another. The trial stay of one month should be increased to three months. Existing residents should be consulted as to how they get on with the prospective new resident. Beach House DS0000061294.V323140.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): 6,7,8,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents were involved in decisions about their lives and were supported to participate in life in the home. Whilst the care plans addressed the needs of residents, more information was required to ensure staff had detailed information about how best to meet their needs. EVIDENCE: Staff work to a key working system, which meant they had particular responsibilities for residents. Residents had been consulted about their choice of key worker, and stated they were pleased with their choice. One relative considered her daughters progress was due to ‘having a key worker she related to’.
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 12 Needs assessed on admission were written into a plan of care detailing how those needs would be met. However, it was not always clear what staff should do to support residents and it was noted that not all residents had signed their care plan. The care plans were written in a suitable format for both the staff and residents. Care plans had been reviewed. The residents looked after their own money with the help of staff, however the type and level of support should be better detailed. Written records were maintained of all transactions. Everyone said they chose to save some money for holidays, clothes, personal items, and entertainment. Residents said that they were involved in making decisions in the home. They had meetings. They had their own their own ‘house rules’ they had agreed on, such as ‘not playing music too loud late at night’. However residents would benefit holding a written copy for reference. Residents knew about risk management. It was the practice of the home to support responsible risk taking and policies and procedures supported this approach. Risk assessments and management strategies were available. Staff were required to sign each risk assessment to make sure everyone knew what to do in these situations. Written comments sent to the Commission gave a mixed view whether staff ‘listened and acted on what they say’. During conversation however, it was evident residents were consulted and able to have their say and join in life in the home. From the minutes seen of the resident’s meetings, a wide variety of topics were discussed such as menus, social activities, and house routines. Beach House DS0000061294.V323140.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): 11,12,13,14,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents were able to make choices about their lifestyle and were supported to develop their life skills. Social, educational, and recreational activities met with the residents’ expectations. Residents were provided with a healthy diet, which they enjoyed. EVIDENCE: Residents said they were given opportunities for personal development. In the kitchen a weekly planner was used to show responsibilities each resident had for housekeeping. Staff helped them where needed. Activities for daily living and recreation were different for each person. This was linked to what each resident wanted and agreed. New residents were
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 14 currently putting a programme of activity together linking in to the college and day centres. One resident said she had gone back to college and talked about how she had achieved good results last year with writing, number skills and computer training. Personal records of achievement were displayed in bedrooms. Residents were able to make full use of community facilities. This included for example shopping; social events and visiting relatives. One resident said he continues to support his local football team and worked part time delivering newspapers. Public transport was used where possible. Staff provided assistance with activities as necessary and had knowledge of events in the nearby area. Since the last inspection the residents had been away for a holiday. All the residents spoken to said that they “really enjoyed” their holiday. One resident said she had been on holiday three times and had a ‘great time’ with her key worker. The visiting policy enabled residents to have visitors at any time and allowed for residents to refuse to see visitors if they wished. Residents said the food was good. It was to their liking. They planned their own menus. Beach House DS0000061294.V323140.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. The health and personal care of residents was based on their individual needs. The principles of respect, dignity, and privacy were put into practice. Appropriate records were in place to manage medication safely, however some improvement in record keeping was required for this to be accomplished. EVIDENCE: The residents’ individual care plans set out the personal support each resident required. Care plans could be better detailed to make it clear what level of support was needed and demonstrate who will take particular responsibility in each area of need. Residents confirmed personal support was provided in private and residents’ rights to privacy and dignity were respected. Resident confirmed staff always knocked on her door and waited to enter. The routines were flexible and
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 16 residents were encouraged to have a bath or shower as frequently as they wished. Staff worked to a key worker system. This ensured residents had a consistent approach to their care. One relative who sent written comments to the Commission considered key working to be ‘good’. ‘It is good my relative was allocated a key worker and it is someone he really relates to’. Residents said they liked their carer and were happy with how they helped them. Some residents were involved with other professional people in their care. This included mental health care. Two residents were currently receiving such support as their complex mental health needs had an impact on residents and staff in the home. The home operated a monitored dosage system for the administration of medication. This was audited by the supplying pharmacist. An appropriate recording system was in place to record the receipt, administration and disposal of medication. However, it was evident that the medication administration record (MAR) did not include instructions for PRN (when necessary) medication administration and two staff had not signed handwritten entries on the MAR sheet. Information sent to the Commission by the provider showed that staff were trained in medication procedures. Beach House DS0000061294.V323140.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): 22,23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents were able to express their concerns and views. In order to fully protect residents, staff must be trained in adult protection procedures and skilled to deal with protection issues. EVIDENCE: Residents in the home were aware they had the right to make a complaint should the need occur. They had confidence Mr and Mrs Zindoga would listen to them. They said they also discussed issues with their carer and at house meetings and were happy with this arrangement. A copy of the complaints procedure was seen during the inspection. Two relatives who sent written comments to the Commission as part of the inspection process were unaware of the complaint procedure. The home had a copy of “No Secrets in Lancashire” and staff had access to a whistle-blowing procedure. Not all staff had been trained in adult protection and managing aggression although Mrs Zindoga said this was being arranged. Staff and residents were vulnerable to physical aggression. One resident had raised the issue of allowing a resident with aggressive tendencies into the home during a residents meeting. Staff also said they needed training to manage such situations, however written guidance was given to staff and risk assessments completed for residents at risk of ‘self harm’.
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 18 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): 24,25,26,27,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home was generally satisfactory; some areas were in need of attention to provide a more comfortable, pleasant, living environment for residents and staff. Residents were able to personalise their bedrooms and create an individual space suitable for their needs. EVIDENCE: Beach House is a terraced property that provides accommodation for six people in four single and one double bedroom, most of which are en suite. The shared space is provided in one lounge, dining room, and kitchen. The home is located approximately two miles from Burnley and is situated on a main public transport route.
Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 19 Residents liked their bedrooms and were satisfied they had everything they needed. Their rooms were personalised with personal possessions such as televisions, pictures, and photographs. Some bedrooms needed redecorating and upgrading as paintwork, wallpaper, and carpets were showing signs of wear and tear. One bedroom was a shared room. There was no record made of two residents staying in this room having been consulted and agreeing to share. Because some bedrooms had en suite facilities this meant residents could attend to personal needs in private. Each bedroom door had a lock on and it was house rules ‘not to go in another persons room without permission’. The lounge area and dining room were comfortably furnished. There were no homely effects such as ornaments or pictures representing ‘family life’. One resident said these had to be removed as one resident ‘smashes things in temper’. A lot of things had been broken such as the large fish tank. Information received at the Commission prior to inspection indicated that some refurbishment had been done, such as the lounge and dining room decorated and new sofas in the lounge. One bedroom had new furniture and a new floor in the bathroom. The dining room ceiling required decoration following water damage and the outside paintwork was flaking. Maintenance and associated records were up to date, such as fire equipment checks and electrical wiring certificate. The home was comfortable, clean, and free from offensive odours, in all areas seen. Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 20 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): 31,32,33,34,35,36, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff in the home were trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: The current level of staffing was linked to the needs of the residents. Relatives who sent written comments to the Commission considered there was always enough staff on duty. Staff were issued with job descriptions, which set out their roles and responsibilities and was linked to meeting the needs of the residents. Residents were very happy with the staff in the home, especially their key worker. One resident described staff as ‘a good bunch now, and we all get on’. Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 21 Eighty percent of staff employed was trained to National Vocational Qualification in care level two or above. In addition to this staff have received other training to help them in their career in social care. Staff said they enjoyed their work. They felt supported and were encouraged to attend relevant training. From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and was observed to interact in a positive and pleasant way. Since the last inspection two members of staff had left the home and new staff had been employed. There was no evidence to show residents were part of the recruitment process, such as being involved in the interviewing. The recruitment and selection procedure did not fully meet with regulatory requirements. Staff had completed an application form and had attended for an interview. Relevant checks had been obtained from the Criminal Records Bureau (CRB). However these were received after employment started and in one instance a CRB was used from a previous employer. Not all applicants had provided satisfactory explanations for gaps in their work history and not all references were available to look at. All new employees undertook an in house induction. Information on the pre inspection questionnaire indicated future training planned included; updating all mandatory training, National Vocational Qualification in care level two and three, managing challenging behaviour, medication training, and risk assessments, demonstrating the staff team had good opportunities to attend various training courses associated with the needs of the residents. Staff meetings were not held on a regular basis, although staff met informally every day at handover meetings. These meetings gave staff the opportunity to share experiences and develop teamwork. Staff received formal supervision, however this was not given regularly. Staff had an annual appraisal of their work performance. Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 22 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): 37,38,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management approach enabled management, staff, and residents to enjoy positive professional relationships with each other and the overall atmosphere was open and friendly. The quality assurance processes must be further developed in order to measure success in achieving the aims and objectives of the home. EVIDENCE: Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 23 Since the last inspection, a deputy manager had been appointed to support Mrs Zindoga in the day-to-day running of the home. Mrs Zindoga has successfully completed the Registered Managers Award. Although formal staff meetings were not frequent, staff met informally during the week to discuss topics relevant to the day-to-day running of the home. Equally residents were given opportunities to ‘have their say’ at residents meetings. Relationships within the home between residents and staff were positive and staff spoke about the residents with respect. In turn the residents described the staff as ‘good’ and ‘helpful’. Those residents who completed written comments had confidence to speak to staff over any issue they had. The home was awarded an Investors In People Award. Satisfaction surveys had not been distributed to the residents and their relative during last year. An annual business and development plan was sent to the Commission that outlined improvements to be made in the near future. Confidential records were locked away. Residents should have a personal copy of all relevant records such as a contract and up to date relevant policies and procedures. Staff received health and safety training, which included moving and handling, food hygiene, first aid, and fire safety. Information contained in the preinspection questionnaire and documents seen during the visit indicated that essential maintenance such as gas and electrical systems, fire safety and water monitoring by contractors carried out. Arrangements had been made to store hazardous substances in a secure location. Health and safety checks were carried out on the environment regularly. Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 24 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 2 2 2 3 X 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 3 2 X X 3 X Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 25 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 YA5 Regulation 5 (1) (ba) (bb) (bc) Requirement The residents must be provided with details of the total fee payable in respect of the service provided and the arrangements for the payment of such a fee. The arrangements in place for charging and paying for services additional to charges must be clearly stated. This is to ensure the residents and their families have clear up to date information about the charges. Care plans must provide detailed guidance for staff on how best to meet the residents’ needs. Residents must be consulted about their care plan and asked to sign, where possible, to indicate their agreement and participation. Staff must have formal training in Adult Protection and managing physical aggression to avoid residents placed at risk of harm or abuse. The communal areas must reflect a homely environment as described in the service user guide. All parts of the home must be
DS0000061294.V323140.R01.S.doc Timescale for action 31/03/07 2 YA6 15 31/03/07 3 YA23 13(6) 30/04/07 4 YA24 23(1)(a) 31/03/07 5 YA24 23 31/05/07
Page 26 Beach House Version 5.2 6 YA34 kept reasonably decorated that includes residents bedrooms. 17, 18, 19 All records and checks for new schedule members of staff must be 2 collated and maintained in line with the Care Homes 14/03/07 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 3 4 5 6 7 8 9 10 11 12. Refer to Standard YA1 YA4 YA4 YA18 YA20 YA20 YA22 YA25 YA25 YA35 YA36 YA40 Good Practice Recommendations It is recommended the home be advertised accurately in the service user guide. It is recommended the trial period offered be increased to three months. It is recommended existing residents are consulted about living with a new resident. It is recommended staff and residents are clear about their role in making sure needs are met. It is recommended hand written additions to medication records be countersigned by two staff responsible for the safe administration of medication. It is recommended medication instructed to be given as necessary have sufficient detail recorded for staff to know the right circumstances to administer it. It is recommended relatives be given the complaints procedure of the home. It is recommended that when a vacancy occurs in the double room, the remaining resident is consulted about sharing and makes a choice of whether to share. It is recommended when a single room becomes vacant it is offered to a resident accommodated in the double bedroom. It is recommended managing aggression training be included in staff induction. It is recommended staff receive regular formal supervision. It is recommended residents be given a personal copy of all relevant records such as a contract and up to date policies and procedures Beach House DS0000061294.V323140.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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
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