Inspection on 06/08/08 for Beach House

This inspection was carried out on 6th August 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beach House 10/10/07

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 08/11/2008.

CARE HOME ADULTS 18-65 Beach House 322 Padiham Road Burnley Lancashire BB12 6ST Lead Inspector Mr Jeff Pearson Unannounced Inspection 6th August 2008 09:30 Beach House DS0000061294.V370699.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.V370699.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.V370699.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.V370699.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. 10th October 2007 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. This information should help people make an informed choice about moving into Beach House. Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people using this service experience adequate quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at Beach House on the 6th August 2008. The visit took over 8 hours The Inspector was accompanied by an Expert by Experience who is a person, who because of their shared experience of using services, visits a service with an Inspector to help them get a picture of what it is like to live in or use the service. The Expert by Experience, looked at the homes’ guide, observed routines within the home and spoke with all the residents. The views of the Expert by Experience and comments received during the visit have been included in the report. The people living at the home and staff were invited to complete surveys, to tell the Commission what they think about the care service provided at Beach House; some were received at the Commission. Before the site visit, the registered manager/owner 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 at the home. The files/records of two people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with people using the service; with the registered manager/owner, deputy manager and staff. Various documents, including policies, procedures and records were looked at. Most parts of the home and some outside areas were viewed. What the service does well: People living at Beach House were being involved with different activities and were getting out into the community and were being supported to gain new skills. On comment made was “I keep busy, I help out gardening and I deliver the free papers” Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 6 Help with personal needs was being given with care and people were being treated with respect. “We decide what clothes to buy and wear,” said on person. People living at Beach House were being given support to stay in touch with families and friends. People were being involved in making decisions about how they spend their time. To help make sure staff do the right things, most had been given training on dealing with difficult behaviours and protection from abuse. Some residents had had helped interviewing new staff for the home, which meant hey had some choice in who supported them. The staff team worked very well with the people living in the home. “The staff are good,” said one person. What has improved since the last inspection? What they could do better: The homes guide could be updated to provide more useful and interesting information. Current residents should not be asked to change or share bedrooms, when a new person is moving into the home. Individual care plans still 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. To make sure people are as safe as possible, all risks must be properly considered and planned for, when promoting independence. To make sure all medication matters stay safe and proper; they should be regularly checked. New staff should be given proper training on medication, to make sure they do the right things. Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 7 To make sure activities and outings can be properly planned for, the staff/manager need to be on duty as written on the rota. 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 still needed changing. To make sure people living at beach House have a nice place to live, the planned redecoration of the home must be carried out. To make sure people living at Beach House get good care and support, the manager needs to be available to properly run the home. 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.V370699.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.V370699.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 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process did not effectively promote informed choices and terms and conditions of residence. EVIDENCE: A copy the homes guide was seen pinned up in the kitchen. Most people spoken with didn’t remember seeing the guide; three said they hadn’t been involved with making it. The expert by experience was given a copy of the guide and looked at it after the visit. The guide received was dated 2004. The expert by experience was good at reading, but found the guide hard to understand and made the following comment “I do not think many people with a learning disability would find it any good. It should be fun, maybe more pictures and bigger writing” The last inspection report was also available in the kitchen. The manager said there had not been any new permanent admissions to the home since the last inspection. However, discussion took place about a person being accommodated for a short stay period. This had meant current residents Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 10 had to change bedrooms to enable the person to be accommodated; with two people who were previously in single rooms having to share. The manager said the residents had come up with this solution. Although it was good practice that the residents were involved with decision making, the Commission considers this change to their terms and conditions of residence should not have been imposed upon them. 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 the admission process was as the previous; people would be invited to visit the home. An admission checklist would be used, to take into consideration relevant areas of need. Including, personal history, communication, physical health, mobility, social well being, financial issues and any other matters. The manager said she was proposing to introduce a new format for the assessment process, which was to be more person centred. Beach House DS0000061294.V370699.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 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care planning was not effective in ensuring people’s individual needs and choices are properly responded to. EVIDENCE: The last inspection showed progress was needed in ensuring people have individual care plans which include details of all their needs and goals, and how they are to be met, to ensure staff know exactly what to do for each person. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated person centred care planning had been introduced, but this inspection showed improving care plans was still in the very early stages with only one person having had their care plan reviewed and produced in a person centred way. The manager said she considered staff needed training in this Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 12 area. Daily records showed progress had been made in ensuring staff record more respectful and reflective comments in care notes. People livening at Beach House were observed to be involved in activities of daily living; for example, they answered the door and telephone. They were asked about day to day matters such as trips out to the shops, meals, activities and other matters. The expert by experience reported that people said they had a choice about where they want to go and could spend their money on what they want to buy. The resident’s said they were having meetings; to discuss menus, social activities, and holidays. Residents completing surveys indicated they made decisions about they did each day. Discussion with residents and staff and observation of support practices, again showed people were being enabled to take risks to support independent living and skill development. Although care records risk showed some risk assessments had been carried out, they were not always clear in explaining the risks or action to be taken. It was again apparent some residents were occasionally staying in the home alone for short periods and were going into the community independently, but it was of concern that no progress had been made in assessing the risks involved and making sure plans are in place to ensure people are safe. The manger said she was working on a training programme in relation to people staying in the home, but this had not yet been introduced. Beach House DS0000061294.V370699.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 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service were being supported to develop their skills, engage in activities and use community resources. EVIDENCE: During the inspection visit people were seen to go out into the local community, some with staff support. The expert by experience spoke with all the people living at Beach House about their interests, hobbies and leisure activities. All indicated they were happy living at the home on said “I really like it”, they spoke of the various things they did, including going to the shops, bingo, jewellery making classes, going to the pub, football matches, gardening Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 14 and college. One comment made was “I like a pint and a game of pool, I can do what I like, the staff will help if I want to do anything else” Records and discussion showed people’s relationship needs were being considered; people were being supported to keep in touch with families, friends and others as appropriate. The residents shared some responsibilities for household chores such as cleaning their rooms and communal areas and washing up; the tasks had been agreed with them, those spoken with were happy to be involved with domestic chores. One person explained, “I do my own ironing” People were seen to have freedom of movement in the building; they could make use of their own rooms whenever they wished, some had keys for their rooms. Two residents said they had to be in their rooms by 10 pm, this matter was discussed with the manager, who explained that this had been agreed with people in their care plans. 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. The expert by experience wrote, “They all seemed okay with the food. One staff said the menus are altered each month, I think the food is discussed when they have a meeting so they have a choice” It was noted that nearly all the food items were super market ‘own’ brands, which staff considered was due to a restricted food budget. The manager agreed to look into this matter. Beach House DS0000061294.V370699.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 and 20 Quality in this outcome area is good 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 met. EVIDENCE: People living at Beach House needed minimal support with personal care needs, it was apparent from observation and discussion they were being supported to choose their own clothing and take an interest in their appearance. “We decide what clothes to buy and wear,” commented one person. On resident spoken with confirmed they were getting help with healthcare when needed, staff had assigned responsibilities for arranging appointments. Individual records showed the monitoring of personal care such as bathing. Health action plans were being devised in consultation with the learning disability nurse team. Some health and personal care matters still needed to be more effectively included in the care planning process. Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 16 Medication storage facilities were satisfactory; the manager said new metal cabinet had been obtained. The appropriate storage of controlled drugs was discussed with the manager. Medication policies and procedures were seen to be available. Clear individual protocols were in place for people prescribed when required and variable dose medication. Records seen were clear and mostly up to date, there was one gap with no explanation given, which meant it was not clear if the person had taken their medication. It was advised a list staff names be kept next to their initials. Records showed medication was being checked; the manager said a more detailed audit of medication was due to be introduced. Not all staff had received guidance and training in administration of medication, but this was being arranged. It was advised staff induction training include more formal instruction on medication procedures. The AQAA (Annual Quality Assurance Assessment) completed by the manager; indicated supporting residents in managing their own medication as plan for improvement. Beach House DS0000061294.V370699.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 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all policies and procedures were effective in promoting the protection of the people using the service. EVIDENCE: The complaints procedure was displayed in the kitchen; it had been updated to include pictures, which may be more helpful for some people to understand. The residents spoken with indicated they were aware of how to make a complaint. One person explained that if they had a complaint they would tell staff. Managing complaints was again discussed with the manager. In particular, devising investigation strategies and ensuring systems make proper provision for recording interviews/discussions and all action taken. People living at Beach House said they were happy there. They commented that they felt safe at the home. The manager said almost all staff had received POVA (Protection Of Vulnerable Adults) training; arrangements were to be made for one new staff member to attend this training. Again at this inspection visit, not all the homes policies and procedures in relation to safeguarding people were available at the home, for example, the procedure for reporting incidents allegations suspicions of abuse was unable to be located. This meant staff did not have access to written instructions on keeping people safe. No progress had been made on updating the information therefore there was still some inappropriate guidance in relation to Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 18 investigating, consent issues, and taking referrals. 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 people using the service. The manager said she was unaware why these matters had not been addressed. Beach House DS0000061294.V370699.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 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The accommodation was satisfactory in providing the residents with a homely and clean place to live. EVIDENCE: It was apparent some were some improvements the accommodation for the people living at Beach House, for example the laundry area had recently been upgraded and a new carpet fitted in the hallway. However, progress was slow and we noted some parts of the home still needed redecorating and upgrading as some paintwork, wallpaper, and carpets were showing signs of wear and tear. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated improvements were to continue. The manager said they had looked areas of the home needing attention, and devised an action plan with timescales for making improvements. The Commission expects the action Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 20 plan will be implemented, to ensure the home provides a good standard of accommodation for the people living at Beach House. All the residents agreed to show the expert by experience their bedrooms and most indicated that they liked them. Although some of the bedrooms were quite small, people had been supported to personalise them with their own belongings, one said, “I like my room”. Two people said they needed keys for their bedrooms; this matter was brought to the attention of the manager. The home was found to be clean and free from unpleasant odours. Satisfactory laundry equipment and facilities were available. Beach House DS0000061294.V370699.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, 33, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The staffing arrangements provided people at Beach House with satisfactory support. EVIDENCE: The expert by experience commented, “I think they all liked the staff a lot. I did not hear anything bad said about the staff”. All the residents were asked if they liked the staff, one said, “They are brilliant” another said, “They are awesome” Positive and sensitive interactions were observed between the residents and staff. The staff on duty had good listening skills and encouraged the residents to explain things themselves. Although staffing levels were generally satisfactory, this inspection showed there was a lack of planning for effective support in response the residents needs and lifestyles. Staffing levels had been reduced due to lower occupancy, staff were not always sure when the manager would be on duty to cover shifts and were unclear about on-call arrangements. The manager said she was having meetings with the deputy about these matters. Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 22 The AQAA (Annual Quality Assurance Assessment) completed by the manager, showed that residents now take part in the recruitment process and ask the candidate some questions. They also comment on whether they feel that person would be suitable to work at Beach House. The staff recruitment and training records were not seen, however, the manager said herself and the deputy had followed all the correct procedures and provided written confirmation of this following the inspection visit. The AQAA showed most staff had NVQ (National Vocational Qualifications) in promoting independence, others had had started this course of learning. The deputy manager was undertaking NVQ level 4. The manager said all staff had completed first aid training, but their food hygiene and infection control training needed updating. Staff spoken with confirmed some training was ongoing and that staff meetings were being held about every six weeks. Beach House DS0000061294.V370699.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, 41, and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all management and administration practices were effective in ensuring the home is run for the benefit of the people using the service. EVIDENCE: This inspection showed some progress had been made to provide better outcomes for people living at Beach House, but some matters had not been sufficiently addressed. Inconsistent management arrangements had affected the general running of the home. Mrs Zindoga, owner/manager was working in the home for 20-25 hours per week, to ensure the home is effectively run, the Commission expects the manager to be in full time day-to-day charge of the home. It was of concern that individual risk assessment and management Beach House DS0000061294.V370699.R01.S.doc Version 5.2 Page 24 was not being properly considered and responded to, also that protection policies and procedures had not been updated, also that the AQAA (Annual Quality Assurance Assessment) provided some unreliable in formation. Mrs Zindoga 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 was to complete an NVQ assessor’s course. The manager said monthly quality audits were being carried out and that residents, staff and management meetings were being held. Quality assurance processes were discussed further; including effectively completing the AQAA, in particular, ensuring it is accurate and used a tool for ongoing quality assurance and developing the service. To promote access to information and communication, it would be useful if Internet access were available at the home. A number of the homes policies and procedures had not been reviewed and updated for some time, the manager explained some had been devised by the previous owners and therefore they were to be reviewed and updated. The homes AQAA indicated the servicing and checking of equipment and installations, records were seen in support of this. Fire drills were being carried out, fire risk assessments were seen. Records showed the last fire safety awareness training had been held in 2005, the manager said this due to be arranged again. Systems were in place to identify and address routine maintenance in the home. Beach House DS0000061294.V370699.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 2 2 X 3 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X 2 2 X Beach House DS0000061294.V370699.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 30/09/08 2. YA23 23 (2) (d) 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. Timescale of 30/11/07 not met. To ensure people using the 31/01/09 service have a pleasant living environment, the planned programme of redecoration must be implemented. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA3 Good Practice Recommendations To provide more interesting and useful information, the homes guide should be reviewed and updated with the residents. To promote the right of agreed room occupancy, the admission of process should not compromise existing residents terms and conditions of residence. DS0000061294.V370699.R01.S.doc Version 5.2 Page 27 Beach House 3. YA6 4. 5. YA17 YA20 6. YA20 7. 8. YA20 YA23 9. YA23 10. 11. 12. YA33 YA37 YA42 To ensure all 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. The budget allocation for food and catering should be reviewed and increased accordingly, to ensure people’s choices are not unduly restricted. 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 management of medication is safe and appropriate, the auditing system should include a more thorough check of all aspects, including records, storage and administration. Action should be taken to ensure the staff induction training, includes more formal guidance in relation to all medication practices. 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. To promote continuity, stability and the planning of service users activities, action should be taken to ensure the staff rota is consistently adhered to. The homes management arrangements need attention, to ensure Beach House is effectively run for the benefit of people using the service. To promote the health safety of people using the service and staff, action should be taken to ensure that training in all safe working practices is kept up to date. Beach House DS0000061294.V370699.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.V370699.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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