Inspection on 27/11/07 for Beachlands Care Ltd

This inspection was carried out on 27th November 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 but made no statutory requirements on the home.

Other inspections for this house

Beachlands Care Ltd 29/08/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Beachlands Care Ltd Marine Parade Seaford East Sussex BN25 2PY Lead Inspector Lucy Green Key Unannounced Inspection 27th November 2007 09:40 X10015.doc Version 1.40 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 Beachlands Care Ltd DS0000067789.V346044.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 Older People. 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. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beachlands Care Ltd Address Marine Parade Seaford East Sussex BN25 2PY 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) 01323 891004 01323 896311 berirvin@aol.com Beachlands Care Ltd Vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-nine (29). Service users must be older people aged sixty-five (65) years or over on admission. 29th August 2006 Date of last inspection Brief Description of the Service: Beachlands is registered to provide residential care to twenty-nine older people. The home is family owned and the proprietors are committed to maintaining a homely environment. Beachlands is a two-storey detached property situated on the seafront in Seaford. The home is located in close proximity to local amenities, bus and rail links. Resident accommodation consists of twenty-seven single rooms and one shared room. Many of the bedrooms have en-suite facilities. The home has a range of communal areas which exceed the amount of space as outlined in the National Minimum Standards. These include a number of lounges and a large conservatory/dining area. The external grounds offer an attractive garden and patio area which overlook the sea. Car parking is available via the side of the property. The home has a passenger lift and a series of ramps which enable residents to access all areas of the home. More detailed information about the services provided at Beachlands, including the range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are on available in the reception area of the home. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Beachlands are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and an unannounced site visit which lasted six hours on Tuesday 27 November 2007 between the hours of 9:40am and 3:40pm. The site visit included a partial tour of the premises and an examination of medication, care and staffing records. The Inspector observed the lunchtime meal being served. Throughout the inspection process, the Inspector spoke with fifteen of the residents individually and observed the way other residents spent time in communal areas. In addition feedback was received from two visitors who were at the home during the inspection. The Inspector spoke with one of the Registered Providers and four staff members, including two Senior Carers, a Domestic and the Cook. What the service does well: Beachlands is an established home which has been recognised as providing a good quality of service for a number of years. The home is family owned and employs a stable and committed team of staff, who know, understand and respect the needs of the people who live there. Beachlands continues to operate as a relaxed and friendly home where residents benefit from the provision of care in a respectful and dignified manner. The Inspector received lots of positive feedback about the home which was repeatedly described as “lovely”, “couldn’t be better” and “can’t fault it at all”. Similarly staff were referred to as “kind” “polite” and “can’t do enough for you”. The home is situated in an attractive location and offers a homely environment for residents to live in. The Registered Providers have a rolling programme of maintenance and strive to give residents a choice of comfortable communal and private spaces to spend their time. The communal space available to residents exceeds the National Minimum Standards. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 6 Beachlands has again been awarded the Clean Catering Award and residents continue to benefit from a choice of freshly prepared meals each day. On the day of the inspection the choice of lunch and supper meals were noted to well presented and appetising. Residents also have the opportunity to speak directly with the Chef, who was knowledgeable about the likes, dislikes and specialist dietary requirements of residents. What has improved since the last inspection? What they could do better: Despite being effectively managed, the home has lacked a Registered Manager since May 2006. A timescale has now been set for this position to filled. New staff must undergo an induction programme that is in line with Skills for Care within the timeframe laid down. Further efforts are required to demonstrate the quality assurance systems in place and where meetings are held with staff and residents these should be recorded to reflect the positive changes that are being made. Beachlands Care Ltd DS0000067789.V346044.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. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are protected by an assessment process that ensures their needs are identified and confirmed they can be met before they move into the home. Beachlands does not provide intermediate care. EVIDENCE: The Inspector viewed the pre-admission assessments information in place for three people who have been admitted to Beachlands in the last twelve months. There was documentary evidence that a representative from the home had conducted a thorough assessment on each individual prior to all three of these residents moving into the home. Where appropriate, social care assessments had also been obtained from the relevant Care Manager. In line with a requirement of the last inspection, the pre-admission form has been reviewed Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 10 and updated to include the information detailed in the National Minimum Standards. A review of the subsequent care plans in place for these three individuals provided evidence that the information gathered at the assessment stage has been appropriately used to develop a comprehensive plan of care. Prospective residents are encouraged to visit the home prior to admission to assess the suitability of the placement and the first two weeks of their stay is regarded as a trial period for both parties. The Inspector met with one person who had moved to the home the day before the inspection. This person confirmed that they had visited the home before moving in and was now giving it a “test-drive”. All residents who were case tracked as part of this inspection confirmed that the admission process had been tailored to meet their needs. There is no provision for intermediate care at Beachlands and therefore Standard 6 is not applicable. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health and personal care needs continue to be met in a respectful and private way. Residents are further protected by the improved systems in place to manage medication. EVIDENCE: A sample of four care plans were viewed and it is pleasing to report that the progress noted in this area at the last inspection has continued. Each resident has a plan of care that provides detailed information about their health and welfare needs, with evidence of multi-disciplinary input as necessary. Care plans contain risk assessments for a range of areas and it is possible to track the level of risk and the controls in place to minimise the risk. Environmental risk assessments for each residents’ room have also now been updated. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 12 There was evidence that care plans and associated documentation have been reviewed on a monthly basis and any changes made are recorded. Discussion with the Assistant Manager who is responsible for reviewing care plans demonstrated that reviews are now undertaken holistically looking at everything that has happened to each individual over the course of the month. This has led to positive outcomes for people and proactive referrals to relevant healthcare professionals. The review for one person showed that the resident had lost weight and this triggered a visit to the GP followed by input from a dietician. Staff practices observed throughout the inspection again demonstrated that they have a good understanding of the residents and their needs. Discussion with staff produced evidence that they have an excellent knowledge about the people they support. Residents spoken with confirmed that they are supported in the way preferred by each individual. It was clear from observation, talking to residents and staff and from the written material in place, that care and support is provided in a sensitive, dignified and respectful way. Throughout the inspection staff were noticed knocking on residents’ doors and seeking permission before entering their private space. Residents are fully supported with their health care needs and care plans contain a record of any visits or contact with professionals external to the home. Any input or advice is then reflected in the relevant care plan and subsequent monthly review. There was evidence of current involvement from General Practitioners, District Nurses, Dentists and Chiropodists. Medication systems were inspected by way of a review of the Medication Administration Records (MAR sheets) and examination of the storage of medication. The medication policy was not inspected on this occasion. The supplying pharmacy undertakes routine checks of medication and it was evident that any recommendations from these visits have been actioned. The home has a good system in place for managing the large amount of medication that has to be administered each day. Since the last inspection a medication trolley has been purchased which allows the safe transportation of medication around the home. Records were clear and it was possible to track changes of medication. A Senior Carer confirmed that only senior staff who have been appropriately trained and supervised handle medication. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to retain choice and control over their lives and benefit from the opportunities to participate in activities if they wish to. Residents receive a choice of balanced and freshly prepared meals. EVIDENCE: The daily running of the home was again observed to provide residents with the flexibility and choice about how and where to spend their time. On the Inspector’s arrival at the home it was evident that routines are respected by staff and residents are able to get up as early or late as they wish. Breakfast is served in bedrooms at a time agreed with the residents – this arrangement was reported by residents to work well and they confirmed that they had choice regarding what they have. During the morning of the inspection, kitchen staff were noticed visiting each resident individually to offer two choices for the lunchtime meal. The menu is also now displayed on each table in the dining room and copies provided in Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 14 residents’ bedrooms for those who prefer to take their meals in their own room. The serving of the lunchtime meal was observed with a choice of either fish or lamb chops, each followed by dessert. The meal looked appetising and well presented. A tour of the kitchen revealed a list of residents’ likes and dislikes which was confirmed as accurate by the Chef. Discussion with staff, residents and a viewing of the menu, identified that residents also receive a choice of meals at teatime. Residents spoken with were complimentary of the food provided at Beachlands. One resident told the Inspector “the food is very good, I have a specialist diet and the Chef always discusses my meals with me”. In a conversation with two other residents it was commented “the food is very good and any likes and dislikes are well catered for”. Since the last inspection, the home has employed an Activities Co-ordinator who works in the home two mornings each week. On the day of the inspection, this individual was observed providing an activity session which was attended by nine residents. Other in-house activities including, craft workshops, aromatherapy and a monthly church service continue. One of the Registered Providers reported that mini bus trips have also been organised, but that these have not always been well attended by residents. Two of the residents spoken with told the Inspector that they would like to see exercise classes available again. The Registered Provider confirmed that this is currently being explored, but that it had been difficult to find an individual who was qualified and willing to provide this service. Residents are encouraged and supported to maintain contact with their family and friends. The home operates an open door policy and residents are able to spend time with their guests in their rooms or in one of the lounges. Visitors were observed being welcomed into the home during the inspection and the visitors’ book evidenced that there are lots of regular visitors to Beachlands. Feedback received from two visitors who met with the Inspector highlighted that they are always made to feel welcome at the home. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from an open culture where they are able to express their views and feel valued and protected from harm. EVIDENCE: Beachlands has a complaints policy which is accessible to both residents and visitors to the home. The CSCI received one complaint about the home which was referred to the Registered Provider to investigate who concluded that the complaint was unsubstantiated. . The residents spoken with all confirmed that they knew how to complain and stated that if they had any concerns they would speak to a Senior carer or one of the owners. The staff spoken with were knowledgeable about the vulnerability of residents and the systems in place to protect them. Staff have received training in the protection of vulnerable adults and prevention of abuse. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents continue to benefit from the clean, accessible and homely environment provided at Beachlands. EVIDENCE: Beachlands is an attractive, detached property overlooking the seafront in Seaford. The home provides level access throughout, by way of a passenger lift and series of ramps and grab rails. Residents are accommodated in single rooms, unless two people express a positive wish to share. Many of the bedrooms have en-suite facilities. Communal space exceeds the National Minimum Standards and offers residents a range of places where they can meet with other residents or their Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 17 visitors. The patio area overlooking the seafront is also a popular place to spend time. It was evident that refurbishment and rolling maintenance programme continues to be ongoing with a number of carpets having been replaced and bedrooms redecorated since the last inspection. There are still areas that require attention, but the Inspector is satisfied that this is being addressed. The home employs domestic staff to ensure the home is kept clean and tidy. One of the Registered Providers also confirmed that the home has recruited a fill-time laundry assistant since the last inspection. The home was found to be clean, hygienic and free from any offensive odour. Conversation with residents and two visitors reflected that the home is always maintained at the standard witnessed by the Inspector. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from being supported by an experienced and committed team of staff, although the home must ensure that robust recruitment procedures are followed at all times, including the implementation of a formal induction programme. EVIDENCE: Conversation with one of the Registered Providers identified that the home has increased staffing levels at Beachlands since the last inspection. The rota, which reflected staffing levels at the time of the inspection evidenced that the morning shift is covered by a Senior carer and two other care staff, with the Registered Provider working in a supernumerary capacity in the place of the Manager. The afternoon provides the same structure, with the exception of one carer working alongside the Senior Carer and the Registered Provider. The Chef works all day, with a kitchen assistant also working in the morning to help prepare the main meal. The domestic team includes three cleaners in the morning and a full-time laundry assistant. At night, the home is staffed by one waking night duty and one sleep-in carer who works waking hours until midnight and then again from 6am. The Activities Co-ordinator works two mornings each week, in addition from care and domestic staff. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 19 Discussion with the Assistant Manager and a Senior Carer provided feedback that these staffing levels were adequate. Whilst some residents stated that they felt the home may be short staffed, it was also confirmed that call bells were answered efficiently and that they receive the support they need, when they need it. Residents needs were also observed being fully met at the time of the inspection. Whilst the Inspector concludes that staffing levels are adequate at the time of the inspection, this must be kept under ongoing review, especially in respect of the afternoon period as individual needs change. The residents who spoke with the Inspector again commented how nice staff were. One resident expressed: “staff are very kind and I am well looked after”. Similarly, another resident stated “staff are very kind, very nice and very polite”. The interaction between residents and staff was again observed to be positive. Staff training is ongoing, with the Registered Provider confirming that over 50 of care staff now hold a relevant National Vocational Qualification (NVQ) to at least level 2. The home has a system for updating training in place and planned updates include manual handling, adult protection, first aid, medication, food and hygiene and fire training. It was again identified that not all new staff had commenced an induction in line with Skills for Care, this was highlighted at the time of the last inspection and is therefore reflected as a requirement of this report. The recruitment files for three care staff were inspected. With the exception of references the required information was in place. One staff member however only had one written reference and another had copies of reference requests being sent to two previous employers, but no evidence of their return. The Registered provider stated that he had recruited the latter person and was confident that the two references had been returned, but admitted that he was unable to locate them. The other staff member was employed by the previous Manager and therefore it was not possible to ascertain why one reference was unaccounted for. The Registered Provider was keen to address this shortfall and immediately following the inspection re-sent for these missing references, for this reason, this issue is not reflected as a requirement, but extra attention must be dedicated to maintaining robust recruitment information in the future. Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from the commitment of a skilled and experienced management team who together ensure that the home is well managed and run in the interests of the people who live there. Further protection and stability would however be afforded by the position of Registered Manager being filled. EVIDENCE: There has been no Registered Manager at Beachlands since May 2006, however the Registered Providers have put a number of systems in place to ensure that the home is being managed. An individual was recruited to this Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 21 position, but did not successfully complete their trial period and therefore were not put forward for registration. One of the Registered Providers told the Inspector that a new manager has been appointed and is due to commence early in the new year. It was agreed that by March 2007, the CSCI must be in receipt of an application for the registration of this person or another suitable individual. Whilst the home is currently being effectively managed, it cannot continue to operate indefinitely without a Registered Manager in post. At the time of the inspection, the management of the home was being undertaken by one of the Registered Providers working full-time at the home in a supernumerary capacity and a Senior Carer who has been promoted to Assistant Manager. The other Senior Carer works opposite shifts to the Assistant Manager. The Registered Providers continue to undertake monthly visits to the home in accordance with Regulation 26. The reports from these visits were available at the time of the inspection. Beachlands is an open and inclusive environment where people are valued and listened to. The home continues to operate with informal systems of gaining feedback, holding meetings and ensuring people’s views are heard and responded to. An annual survey has also been produced for residents and visitors, but at the current time there is not formal mechanism for utilising and publishing this feedback. It was therefore again discussed with the Registered Provider that the home needs to develop more formal systems of self-audit and gaining feedback, in order that the home can demonstrate how it is continuously improving. As part of this process, regular recorded supervision sessions should be happening on a one-to-one basis for staff. Residents’ finances are safeguarded by a system that ensures all transactions are logged and receipts maintained. The Registered Providers are the only people who handle residents’ money. The information submitted to the Commission by way of the Annual Quality Assurance Assessment indicates that the home has a number of systems in place to ensure the health and safety of the home is monitored and maintained. The Inspector did not therefore look at records pertaining to the maintenance of equipment and routine testing. A review of risk assessments did however identify that the environmental assessments have now been updated in line with the requirement made at the last inspection. The home has also been awarded the Clean Catering Award 2007 Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 18(1)(c) Requirement The Registered person must ensure that all new staff undergo an induction programme that meets Skills for Care specifications, within the times set down by the National Training Organisation. The Registered Person must submit an application for the registration of a Manager. The Registered Person must ensure that a formal system of monitoring quality assurance is put in place. This should include regular recorded staff supervision and staff meetings. Previous timescale of 01/11/06 not fully met. Timescale for action 01/01/08 2. 3. OP31 8(1) 24 01/03/08 01/03/08 OP33 Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Beachlands Care Ltd DS0000067789.V346044.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!