Inspection on 13/12/06 for Beaconhurst

This inspection was carried out on 13th December 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaconhurst 16/08/07

Beaconhurst 26/06/06

Beaconhurst 02/12/05

Beaconhurst 17/06/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Beaconhurst 1 Gorge Road Sedgley West Midlands DY3 1LF Lead Inspector Deirdre Nash Unannounced Inspection 13th December 2006 10:30 Beaconhurst DS0000062601.V322870.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 Beaconhurst DS0000062601.V322870.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. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaconhurst Address 1 Gorge Road Sedgley West Midlands DY3 1LF 01902 882575 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) Minster Pathways Limited Mrs Sandra Anne Bebb Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2006 Brief Description of the Service: Beaconhurst House is an independent sector Care Home that was registered in the latter half of 2005. The maximum number of service users it can provide care to is three. The service user group is younger adults with learning disability and autism. The home is a converted private residential property located near to Sedgley. It is within easy travelling distance of the local town, community facilities and a public transport network. Accommodation is provided over two levels. On the ground floor is a large reception area. Bedrooms are spacious and are on the ground and first floor. Each service user has their own bedroom and their own identified lounge. A lift and other facilities for Service Users with physical disabilities are not available. There is a large garden area to the front and rear of the property, and off road parking facilities are available for visitors. Fees range from £1780.33 - £1888.00 per week. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We looked at all of the information that we have received about this home since it was last inspected. The Inspector called at the home without notice mid morning, spoke with the manager and three members of staff, met three residents and spent a few minutes with one, looked around the home and looked at records. The care of a sample of one resident was followed in this way to see if the home is providing a service that meets the national minimum standards. Residents appear generally well. They look healthy and well looked after and can communicate comfortably with staff. What the service does well: The home provides at least one to one care and attention for its residents. All current residents are young men. Managers and staff get to know the residents well and welcome their families. Each resident has an assessment of his needs by social services, health trust and/or by the manager of the home. The home produces thorough individual plans for their care for staff to follow. These plans weigh up the benefits and risks involved in ordinary daily events and leisure activities so that residents can live an active life in relative safety. The home is commended for the quality of these care plans. Residents can choose their meals and staff do encourage healthy eating. The home makes sure that residents get routine as well as specialist health care. Staff are properly recruited, trained and supervised. Residents are helped to keep busy and get out and about as part of their care plan. They are also encouraged to contribute to the day-to-day housekeeping if they want to. Staff see their job as helping each resident to ‘be his own man’. The home is kept clean and fresh. Residents each have their own bedroom, lounge and bathroom and these show the personality of the individual that lives in it and are used by residents throughout the day as they please. One resident said “Its my flat, its nice”. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information about the home is available and the home obtains or carries out a full assessment of needs of prospective residents before they are admitted. Residents live in a home that can meet their needs. EVIDENCE: The manager reports that the statement of purpose and service user guide have been recently updated. One resident has been admitted since the last inspection. We saw a comprehensive assessment of his needs undertaken by the manager over three visits to him at his previous place of residence during August 2006. His file also contains an NHS psychology assessment dated November 2005 and a social services and health nursing recommendations and residential care requirements document for him dated October 2005. All assessments included references to risk. We looked at the file of one of his key workers and saw an NVQ in Health and Social Care Award certificate and certificates of attendance at very recent course in ‘strategies for crisis intervention and prevention’ (SCIP) for working with behaviour that challenges. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 9 The manager reports that all support workers at the home will be attending some autism awareness and epilespy training in the new year. The staff team has been increased during the day and the night to meet the needs of the new resident. We saw that two staff are available solely to him in the house and that three staff go out with him. The roster from 11th to 18th December shows two staff working each night. The manager reports that to meet his needs both are now waking night staff. There is no contract or written terms and conditions for care and accommodation in this residents file. The manager reports that a substantial document has been received from the social services department for this new resident and it is currently with the provider organisations finance department and will be put on the residents file in due course. We will follow this up at a future inspection. The home has made significant improvements across this group of standards since the last inspection. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 10 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, 9,11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home produces comprehensive and wide ranging care and support plans for each individual that are underpinned by risk assessment and show how and where individuals can make their own decisions. Resident’s needs, goals and aspirations are reflected in their plans of care. EVIDENCE: We looked at the care file of one resident who was admitted to the home in September 2006. The file contains a comprehensive range of clearly written support plans for his daily and nightly care cross refererenced where appropriate to written risk assessments. The risk assessments were signed by key staff to show that they had read and understood them. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 11 Support plans include strategies for helping the resident to make day by day decisions and we saw this supported by daily records and by what we observed through the day of inspection. For example we saw that one resident chose to stay in his bath for for a number of hours while we were at the home and that staff safely made this possible. Daily records make clear where any choice expressed by the resident has been denied and why. Discussion that we had with staff confirmed that the approach with all residents is to help them to be their own man as far as safely possible. One worker said ‘our job is to reduce the stress that they feel not to increase it. We try to give them a happy life. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 12 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, 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. The home helps residents to enjoy a reasonable range of activity and leisure and family relationships are supported. Residents have a lifestyle suited to their age. EVIDENCE: The support plan that we saw for our sample resident shows leisure and community opportunities underpinned by assessment and management of the risk involved. There are instructions for minimum staff levels for inside and outside the house. The home has transport. One resident has his own car that staff drive for him. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 13 We found that one resident was out when we arrived at 10.30 a.m. and he returned from the shops at lunch time with his new clothes. The resident who’s care experience we ‘sampled’ went out with three staff for a two hour walk in the afternoon. We saw photographs taken last month of his birthday party in his flat at the home including older and young members of his family. We saw a receipt for ten pin bowling in November in his finance file. Another resident that we were able to speak to confirmed staff reports that he had been driven to the Yorkshire Dales on the day before our visit. The newly admitted resident is of college age; the manager reports that they are working on discovering his leisure interests with him. As he missed a considerable amount of his schooling we recommend that the home also focus on providing him with some continuing education opportunities. His daily records showed also that for three days at the beginning of December he asked to go out and was denied each time. Although reasons were recorded, for example refusing a walk because of ‘bad weather’ there is no indication that a manager reviews these daily records and forms a view as to whether these refusals are reasonable for a young and physically healthy man. We make a good practice recommendation to improve this. The manager reports that residents are not pressed to associate with each other, they prefer to be alone and we saw evidence of this through the day that we were there. We saw a support plan in the file of our sample resident for sexual needs. We saw fresh vegetables and potatoes being prepared and cooked to go with meat and gravy or fish and sauce in the middle of the day. Staff report that experience has shown that these three individuals eat better at that time than in the evening. One resident confirmed that he had a Chinese take away meal on Monday and on Tuesday because it was what he wanted. We saw fresh fruit and salad in the kitchen and the cupboards and freezer are well stocked with tinned goods and meats. There are good clear pictures available to help residents to choose their meals. We saw records of meals taken by our sample resident in his care file. He is on a gluten free diet and his food was seen stored in a fridge and cupboard separate to the rest in the kitchen. At lunch time the house smelled of good food. Residents eat their meals in their own flats; there is no communal dining. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 14 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 good This judgement has been made using available evidence including a visit to this service. Personal and health care is detailed and reviewed in individual care plans and staff consult those plans. Residents get good healthcare and receive personal support in the way that they prefer and require. EVIDENCE: The care file for out sample resident shows health documentation including nutritional risk assessment, up to date record of food taken and a weight chart. There are no records of routine health appointments or a health action plan however. The manager reports that these are yet to be organised, as this resident has been at the home only a short time but that health care plans and routine appointments are in place for the other two residents. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 15 Care plans for our sample resident showed detailed directions for staff for his personal care. These were crossed referred to risk assessments. We saw staff administering medication on two occasions through the day from the office where the medication is securely stored. Each administration was undertaken by two staff and checked and signed for. The records of medication (MARS) for our sample resident are complete and a list of his medication and its side effects are in his care file. We spoke to the senior on duty who has special responsibility for medication in the home. She confirmed the managers report that all staff are undertaking the distance learning 4 module course in safe administration of medication. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 16 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 good This judgement has been made using available evidence including a visit to this service. The home has a complaint procedure and staff are clear about their duty to report poor practice and concerns about residents well being. Good policies, procedures and an ethos in the home of valuing people protect residents. EVIDENCE: All three current residents are strong young men and can be very challenging. We saw staff treating them all with affection and respect. The senior that we spoke to described the work that is being done within the staff team to manage communication with individual residents in ways that reduce confusion and promote positive behaviour and psychological well-being. Our observations throughout the day supported what the manager told us that the ethos of the home is to support residents to do as they chose within the limits of managed risk and not to just control them. Referred to above we saw staff making it comfortably possible for one resident to stay in his bath for a number of hours. Staff that we spoke to supported the managers comments that this ethos has reduced the number of incidents for each individual over the past weeks. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 17 Staffing levels are high with our sample resident having two staff available to him at all times in the house, including at night, and three staff when ever he leaves the house. Staff report that they are undertaking training in protection from abuse in the new year. One member of staff was seen reading the adult protection procedure when we arrived using this time as his key resident was staying late in bed. There is a complaint procedure and a copy is in each residents care file and in picture story form although these particular residents may not be able to understand it. Our direct and indirect observations through the day however showed that staff respond closely to each individuals mood changes and reactions to events and acknowledge these by ‘reflecting them back’ to the resident. For example when one resident became upset and said repeatedly ‘what’s wrong with me?’ a member of staff responded ‘you’re saying that there is something wrong with you. Lets think about what that could be’. There is a formal complaints logbook. The manager reports that no complaints have been received by the home since the last inspection. We have had no complaints about the home either. The manager is a SCIP trainer and we saw circumstances and agreed and approved methods of restraint for our sample resident is in his care plan. One incident had been written down in his daily notes. Staff report that the manager sees all restraint report forms that are filled out by them. The file of a key worker for this resident showed a SCIP training certificate dated 7th December 2006. We checked a sample of the financial records of spending money only, for our sample resident. Receipts match expenditure and the balance matched the money in his wallet kept in the office safe. Three out of the last five entries had only one staff signature however and the policy of the organisation is that there must be two for the protection of resident and staff. We asked the manager to look into this and monitor and improve these records. We will follow this up at the next inspection The manager reports that the Provider company is appointee and holds all money belonging to our sample resident pooled in an account called residents account with some other service users monies. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 18 Although we accept that this has been done for his own protection and the organisation audits this account on behalf of each resident it is not an ideal practice. The manager has agreed to investigate other means of holding and managing his money. In the meantime we recommend that social services be consulted about the current arrangements for him. Beaconhurst DS0000062601.V322870.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): 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 is generally well decorated, well maintained, kept clean and fresh and there are no oppressive security arrangements in place. Residents live in a comfortable home that offers them a life style suited to their age. EVIDENCE: We saw around most of the house and grounds. The house is laid out roughly into 3 flats with one flat being more self-contained than the other two. Each resident has a bedroom, sitting room and bathroom. Two flats have personal items in them but the quality of apparent comfort in the third is very different. The manager reports that the home is making some progress with this resident in gaining his acceptance of some objects and furnishings in his space. We will follow this up at the next inspection. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 20 New flooring had just been laid in the ground floor hallway and one of the bathrooms is being completely refurbished in the new year. The house was generally clean and tidy and kept fresh by staff. There are no oppressive security measures in place although the garden is secure on risk assessment for each individual. We saw this in the care file of our sample resident. There are some local shops across the road and Sedgley Beacon; a high level common with views over the west midlands is within walking distance. There is room for cars and a mini bus in the grounds of the home. The kitchen is homely and well kept and the fabric of the house is in reasonable condition. There is no communal space accept the kitchen and gardens and this is positive for these individuals who do not respond well to group living. The domestic washing machine is in a shed in the garden. The care plan that we saw for our sample resident included encouraging him to participate in some household chores if he wishes. This machine could be moved into the L shaped kitchen if a robust infection control procedure was put in place. This would contribute to ordinary home life. There is alcohol hand wash in bathrooms where soap and towels cannot be safely left out. We saw staff using dissolvable laundry bags and gloves when dealing with soiled linen. Records show that four staff have undertaken infection control training in the past twelve months. Beaconhurst DS0000062601.V322870.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): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are properly recruited, trained and are supported by seniors. A professional and well-motivated team looks after residents. EVIDENCE: The entire staff team with the exception of one permanent night worker has joined the home since September 2006. Staffing levels are high and the team is carrying two vacancies. The manager reports that all staff are experienced in working with autistic adults/learning disabled adults and that many hold either level 2 or 3 in NVQ Health and Social Care. One senior has Level 4. We saw an NVQ Level 2 certificate dated October 2006 in the key worker file that we sampled and references showing previous experience in this role and with this service user group. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 22 The manager reports that the Provider organisation is committed to getting the whole team qualified. This is very positive. We saw LDAF (Learning Disability Award Framework) Induction and Foundation dates on the notice board and the manager reports that staff are being slotted into dates as they are available and that autism and epilepsy training is planned to follow when progress has been made on statutory health and safety training. We will follow this up at the next inspection. The personnel file for a key worker of our sample resident contained most information required for the protection of vulnerable people. There was a POVA First check email but no CRB (Criminal Records Bureau) Enhanced Disclosure certificate. The manager reports that she did see the certificate for this worker when it arrived but it was sent to head office and had not yet been returned. She undertook to get it back onto the premises where it should be unless the organisation writes to us and obtains our agreement for them keeping these records centrally. We will follow this up at the next inspection. The manager reports that dates for one to one supervision of staff have been diarised for next year but we saw no evidence of this in the file that we sampled. The manager and staff have been working at the home only since September so we will follow this up at the next inspection. Beaconhurst DS0000062601.V322870.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, 38, 39, 42, 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well run with a clear internal and external management structure. Service users live in a home that is run in their best interests. EVIDENCE: Evidence gathered and observations made throughout the inspection clearly demonstrate that the ethos and management of the home is to the benefit of the residents. Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 24 Staff spoken to say that incidents of challenge and distress in all three residents have shown a marked decrease over the past few months and the residents coped well with having an Inspector in the house. They appear well and well looked after and all were seen smiling or heard laughing at some time during the day. The house was calm but active and there is a clear sense that it is the home of each resident and that each is entitled to a life and to be his own man. Staff are well motivated and those spoken to report clear and inclusive management and good leadership from the registered manager. The manager tells us that she receives good support from the service manager. We have no record of receiving regulation 26 visit reports from the Provider organisation about this home recently. Such a visit had taken place the day before this inspection. We spoke to the service manager who was present for the inspection feedback. As the home has had three managers in 18 months we need to be confident that the organisation will properly support the new manager and want to see monthly regulation 26 reports between now and our next inspection visit. This is a requirement. We found no evidence that the service is being regularly checked for quality. The manager reports that a survey of stakeholders is being undertaken. We will follow this up at the next inspection. We looked at a sample of fire safety test records and food safety test records and found them to be in good order. There is a written fire risk assessment and hazard action sheet for the house. The registration certificate is on display and the insurance certificate shows valid cover This service has made remarkable improvements across all groups of standards since the last inspection in July 2006. Beaconhurst DS0000062601.V322870.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 3 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 3 3 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 3 3 3 x 4 4 2 x 3 3 2 Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 26 NO 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 YA43 Regulation 26 Requirement The registered person must ensure that the registered person or delegate makes a monthly visit to the home. A copy of the report of each visit must be sent to the CSCI until the next regulatory inspection takes place. Timescale for action 15/01/07 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. Refer to Standard YA12 YA13 YA23 Good Practice Recommendations Arrange continuing education opportunities for the 19year-old resident. The manager should monitor the reasons given for refusing residents community access whenever they ask to go out. Consult social services about the arrangement for managing the finances of the resident identified at this inspection. DS0000062601.V322870.R01.S.doc Version 5.2 Page 27 Beaconhurst Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Beaconhurst DS0000062601.V322870.R01.S.doc Version 5.2 Page 28 - 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. 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