Inspection on 17/06/05 for Beaconhurst

This inspection was carried out on 17th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 34 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaconhurst 16/08/07

Beaconhurst 13/12/06

Beaconhurst 26/06/06

Beaconhurst 02/12/05

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 Deborah Sharman Announced 17 June 2005 th 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 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 Stationary 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 E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beaconhurst Address Beaconhurst, 1 Gorge Road, Sedgley, West Midlands, DY3 1LF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 882575 01902 671158 Minster (Pathways) Acting Manager - Ms Yvonne Williams Care Home - personal Care 3 Category(ies) of Learning Disability 3 registration, with number of places Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection Not Applicable Brief Description of the Service: Beaconhurst House is a newly registered independent sector Care Home, which is registered under the Care Standards Act 2000. 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 Sedgely. 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. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This first inspection began at 9.00a.m and finished at 6.30p.m. The Inspector planned to familiarise herself with this new home and to primarily assess those core Standards that directly affect the experience of service users (1, 2, 4, 6, 9, 12, 15, 19, 20, 24-30, 33 and 34. Given time spent assessing recruitment due to concerns identified time did not allow for a full assessment of medication (Standard 20). This will be assessed at the following inspection. It was found that at the time of inspection only one service user was accommodated and had been resident for 2 weeks. It would be usual for the Inspector to seek the views of service users but given the service users needs and the short time he had lived there it was felt not to be appropriate on this occasion. The Inspector did however have the opportunity to ‘interview’ at length a member of staff. In addition the Inspector toured the premises and assessed documentation. Although areas for immediate improvement were identified and the nature of them gave rise to significant concern, a firm foundation for good practice is being established in some areas (choice, recording care practice in daily notes) and the Inspector looks forward to seeing the ongoing development of the home. What the service does well: This is a new service and the environment provided is light and spacious with each service user having their own bedroom and a lounge area. Each service user is also allocated their own bathing and toilet facilities and does not have to share. There was good evidence both observed and documented of choices afforded by staff on a daily basis to the service user admitted to the home. It was pleasing to see a care plan in place in a workable format for the service user who had been admitted only a fortnight prior to the inspection. It was encouraging too to see that this care plan builds upon the service users abilities and that dignity is also encompassed. The staff, Acting Manager and Proprietor engaged positively with the Inspector and the inspection process throughout what was a long day and responded positively to constructive feedback where shortfalls in provision were identified. The Acting Manager said she had received a lot of support from the company and she felt that the home had helped the new and first service user to settle Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 6 in ‘amazingly well’. A staff member spoken to said that he felt a strength of the home was that they ‘have definitely got a good team, with good morale’ and that individuals in the team support and encourage each other. It was pleasing to see that staff had tried to explain the Service User Guide to the new service user within 48 hours of emergency admission, (this is a document to familiarise new service users with rules and routines and rights) and pleasing too that they had recognised and responded to the fact that this was an inappropriate time for this service user. The home has demonstrated its commitment to supporting service users with complex needs to access the community. What has improved since the last inspection? What they could do better: This service was registered on 4th February 2005, 4 months prior to admitting its first service user. It was therefore disappointing (given the time the home had had to prepare) to issue a number of immediate requirements to ensure an immediate improvement in a number of areas. Recruitment procedures and practice are inadequate. Checks required had not been sufficiently undertaken for the majority of the staff and were also not in place for the Acting Manager compromising the safety of service users. In addition an assessment to minimise the risk of fire had not been carried out and fire training had not been provided to staff. The service user admitted to the home is assessed as having behaviour that can challenge and his assessed need is to have staff appropriately trained. This training had not been provided prior to his admission. This is concerning as many of the new staff group are new to the care profession. In addition action had not been appropriately taken to promote the dietary needs of the resident admitted. Systems were not in place for this and full fat fresh milk and fresh food produce was not available either. All of these shortcomings were subject to immediate requirement by the Inspector to ensure rapid remedial action to ensure a better performance by the home. Health needs must to be better planned for in order to ensure that routine and specific health screening is provided. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 7 Infection control is not sufficiently addressed and the laundry environment (shed) compromises this. Thirty-seven requirements for improvement including immediate requirements have been issued as a result of this inspection. 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. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4,5 Documents must be in an appropriate format for service users to ensure usefulness in decision-making. Attention to terms that are weighted in favour of the provider must be addressed before these standards are fully met. EVIDENCE: The home has a Statement of Purpose (April 2005), which covers most of the required areas. Omissions identified by the Inspector include fees charged, what they cover and the cost of extras, the amount of communal space available per service user and whether this does not meet, meets, or exceeds the National Minimum Standard. This document must be reviewed. The home is also required to review its Statement of Purpose to ensure the accuracy of information provided in relation to staff qualifications, as in all cases evidence has not been seen. The home also has a service user guide, which includes most required information with the exception of the size of communal space available. It states that the fee charged is in line with Local Authority rates. The guide is a written one with dense and small type and is therefore not in an accessible format. The Acting manager felt that the current service user would benefit from a guide in audio format. There was documented evidence that staff had tried to go through the service user guide with the resident upon admission but that he was not ready to respond positively at this time. This must be kept under review and the need to do this at his pace not overlooked. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 10 A very comprehensive and useful need assessment had been provided by the placing social worker in respect of the service user admitted prior to admission. Trial visits were not thought to be in this service users best interest although this is not documented. Unfortunately the plan for staff at the home to ‘visit’ the service user on a planned basis did not materialise, as the placement was in the end an emergency. Therefore the home had not undertaken a holistic assessment prior to admission but a risk assessment had been done. A care plan was in place with good detail although it did not sufficiently cover nutrition as per assessed need and the identified need for staff trained in challenging behaviour had not been met prior to admission. Behavioural guidelines were in place in great detail and consistent with the method used by the home but were significantly too ‘scientific’ for staff to follow that had not received this very specific training. Family carers interests / needs / had not been addressed in the care plan as per Standard 2.8. It was pleasing to see a contract of residence in place that had been signed by the service user. There are however some concerns about its content and some omissions requiring review. The space for the fee had not been completed. In respect of fees the contract also states that fees will be reviewed it is not stated how much notice will be served prior to any increase. The trial period is also referred to as 4 weeks. It must be 12 weeks (standard 4.3). Section 17 states that the home ‘reserves the right to move service users between rooms and between single and double rooms if deemed necessary’. Standard 5.2i states contrary to this the contract must specify the room to be occupied. This is to prevent service users being disrupted for the convenience of the service and to ensure stability and security for the service user. In addition the contract says that the chiropodist, physiotherapist and hairdresser make regular visits and that charges will be made to the service users personal account. This does not recognise service users’ rights to choose to utilise national health facilities without charge and requires review. Fees are not adequately addressed in either the Statement of Purpose or contract of residence. The Acting Manager demonstrated a good knowledge of the need to offer trial visits and it was pleasing to see documented evidence of staff attempting to explain the Service User Guide. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9 The home has a satisfactory care-planning format and most of the needs of the service user accommodated were addressed. Significant areas of need had been overlooked in the care planning process, potentially compromising the health of this service user. EVIDENCE: It was pleasing to see a care plan in place for the service user admitted to the home. The format of the care plan is easy to follow and significantly is positively based upon the service users abilities as well as needs, which is good practice. The care plan covers the following areas: waking and sleeping patterns, toileting, dressing, bathing, showering (it is stated that the service user prefers hot showers in preference to baths), washing, teeth cleaning, hair care, eating and drinking, health / medication (too brief), individualised hobbies and interests, behaviour and household tasks. Correctly it is largely based upon needs identified by the placing social worker although where the social worker has stipulated that 3 month medication reviews are required based upon 3 monthly blood tests, the care plan for blood tests states ‘regular’. The care plan must be adjusted to ensure the time scale is specifically stated i.e. 3-month blood tests. The residents care needs assessment states that the service user requires 1: 1 staffing throughout the Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 12 day. This must be stated on his care plan. His care plan does state that a staffing ratio of 1:1 is required when out in the community. Behaviour / physical intervention guidelines are in place but would mean little to staff not provided with the training. Care plans must also include routine health screening such as dentist, chiropodist, and optical checks, hearing checks and testicular screening. These checks must be planned for annually as a minimum. The service users care plan did not address the significant area of nutrition and was subject to immediate requirement to ensure improvement. This service user is assessed as underweight and ‘needing a good diet’. This is included as an identified need in his community care assessment undertaken by the placing social worker. His weight was not taken upon admission to the home. In addition a nutritional risk assessment has not been undertaken and a nutritional / dietary care plan is not in place. There is no evidence that a fortified diet is being provided and it would appear from discussion that it is not. The service user referred to likes to drink milk. The only milk available on the premises is skimmed and long life, which is not appropriate for someone assessed as underweight. Food intake is being recorded. This is positive but could be improved by noting quantity consumed. Within the intake records there is evidence of the service user frequently refusing to eat e.g. week beginning 6 June 2005 he refused nine meals in total. The template for recording meal intake includes space to record mid morning snacks but these are not completed to evidence that mid morning snacks have been offered. Systems to review care plans were not assessed given the admission of the first service user only a fortnight earlier to the home. The acting manager is reminded that systems are required to monitor and evaluate all aspects of the care plan. Decision making (standard 7) was not fully assessed but there was good documented evidence within records of choices offered and made by the service user. Choices offered were ‘do you want to go to Tesco’ and ‘asked X what he wanted for lunch…he chose etc’. This is good record keeping. An area for improvement was identified. Records indicate that the service user was taken to the local indoor shopping centre. It was recorded that the service user told staff he was ‘very happy’ and asked if he could go again the following day. Records for the following day show that the service user did ask if he could go out and it is recorded that he was offered the option of going to a local park, which he accepted. Whilst the detail in the recording is very commendable it appears that the choice of the park was the staff choice. It is important that staff use records to ensure continuity of care. For example the records from the previous day should have been read by subsequent shifts and the service user offered the option of returning to the shopping centre and his response recorded. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 13 In order to protect the service user following the issue of immediate requirements as a result of inadequate recruitment checking processes the service user who had moved in suddenly a fortnight earlier was moved on the day of inspection to another company home in another area where staff had been checked. Poor recruitment practice has ultimately denied this service user choice and stability. Risk assessments had been undertaken. A general and wide ranging one had been completed prior to the service users admission and another was in place to address going out in the mini bus. Control measures were not always clear or fully complete. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13,15,17 Community access is good. Systems are not in place to ensure that assessed nutritional needs are met and performance is poor. EVIDENCE: It is accepted that the only service user accommodated is very early into the period of his placement and the two weeks prior to inspection were a settling in period, which the staff and Acting Manager felt had gone very well with positive outcomes for the service user who had not demonstrated any signs of distress (this is evidenced in documentation). As someone new to the geographical area of the home he was not able to continue to take part in activities established prior to entering the home. There was however clear evidence that the service user had been facilitated to access the community frequently. It was pleasing to see that the home has assessed the service users interests and that these are clearly recorded, many of which were evidenced as available to the service user within the home. As the service user is not going to be attending formal traditional day care, the acting manager is required to ensure that a recorded programme of activity is agreed with the service user where possible, based upon his preferences and wishes. This programme of activity must be monitored, evidenced and kept under review. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 15 Links with family and friends for this service user had not been assessed or included in a plan of care. Visits from previous carers however had been recorded. It is the home’s policy that family and friends are welcomed to visit the home. The provision of a lounge for each service user enables visitors to be appropriately received in private. The home’s policy on sexuality was not assessed on this occasion. A menu was available based upon, the Inspector was told, the service users expressed preferences. Expressed food likes and dislikes are not recorded and must be. The food intake record demonstrates a variety of meals. Bananas were available but otherwise there was no fresh vegetables or meat on the premises. Records indicated that the service user had been enabled to help with food shopping and preparation. It was pleasing to note that the care plan explicitly stated the service users preference at mealtimes. Mealtimes were observed as flexibly fitting around the service users activities and were at the service users pace which is stipulated in his plan of care. Much of the practice in relation to Standard 17 (meals and meal times) is positive but has been scored low to reflect the need for an immediate requirement in relation to nutritional awareness. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The plan of care does not provide staff with sufficient guidance to proactively meet the health needs of the service user. EVIDENCE: The care plan for the service user admitted to the home must be expanded to include the required routine screening – dentist, optician, hearing, chiropodist and testicular. Routine screening must be at least annual. The specific need of the service user to have 3 monthly blood tests must be included too and actioned with evidence. As the service user had only been resident for 2 weeks no routine screening or other health appointments had been undertaken or had been required. It is important that this process begins as soon as possible with the consent of the service user. It was pleasing that he has registered with a local GP as his previous was out of area. Immediate requirements have been made to improve practice in relation to nutrition and weighing service users upon admission and regularly thereafter. Care plans contained good guidance to minimise anxiety promoting the mental health needs of the service user. The home’s service user guide outlines various models of care employed to support the needs of people with autism and training will be required to support the implementation of these. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 17 There is evidence that staff are prompting the service user to use the toilet to promote continence and dignity but several recorded ‘accidents’ suggest that the strategy needs review. No accidents are recorded in the accident book. The Acting Manager reported that there have not been any. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These Standards were not assessed. EVIDENCE: These Standards were not fully assessed but will be assessed at the following inspection. A service User was admitted to Beaconhurst on 1st June 2005. He has behaviour that can challenge. His Community Care Assessment / care plan undertaken by his placing social worker indicates that staff must have the required training in managing challenging behaviour and physical intervention. Five staff appointed to this new service are new to care, other staff have been trained in alternative methods contrary to the policy of the home which adheres to a specific model of physical intervention. Training has not been provided to ensure that staff can safely meet this service user needs. A behaviour plan is in place and care plans look at how to diffuse situations that may trigger increased anxiety. However the physical intervention plan, which is not signed or dated, would be meaningless to staff without the specific training. It was an immediate requirement to ensure that this training is provided and the Inspector discussed with the Acting Manager the expectation that this would be carried out without delay whilst the service user was temporarily accommodated elsewhere to enable recruitment checks to be carried out properly. If the service users return risks being delayed by this then Social Services who are commissioning the service on behalf of the service user must be consulted. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 Performance is inconsistent, ranging from poor for infection control, to commendable for the provision of toilets and bathrooms. EVIDENCE: The premises are spacious and light and odour free. All bedrooms are single and not shared. Rooms without service users have not been furnished but areas occupied by the first service user to be admitted are homely and personalised. The premises are domestic in style. The entrance hall displayed the home’s registration certificate. Insurance certification was also displayed but had expired. The Inspector was reassured that a new one was in the post but this must be displayed up to date. A signing in book is available and the Inspector was asked to sign in. Large windows to the bedrooms provide a view when seated and radiators throughout the building are guarded. Locks are of the thumbscrew type, which can be over ridden externally with the exception of the front door that requires a key upon entry and egress. This must be verified with the Fire Department. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 20 Bedrooms are well furnished. There is adequate space in bedrooms for a second easy chair and table but these have not been provided as per National Minimum Standard. Bedrooms are not equipped either with a lockable facility. These must be provided unless there is a recorded reason for not doing so based upon the expressed and recorded needs or wishes of service users. Rooms are not fully occupied so a decision cannot yet be made in respect of all rooms. The availability of 2 double sockets, a TV aerial and telephone point was not assessed but will be at the next inspection. All other facilities were available within bedrooms including new carpets. The bed in the occupied bedroom was furnished without a valance and this tarnished the otherwise high quality of the room. All bedrooms exceed the spatial requirements of the National Minimum Standard. Communal space available per service user is not stipulated and requirements have been made. Lounges have been attributed to each service user based upon their anticipated needs for sufficient space given the home’s intention to admit service users with autism and associated challenging behaviours. Bedrooms are heated with a covered gas heater. Carbon monoxide warning detectors are not fitted. The ground floor bedroom has a door which via a thumb screw mechanism exits to the outside of the property. It is essential that this is risk assessed prior to occupation. The acting manager indicated that the exit might be restricted. Prior to this the advice of the Fire Service would be required. A large low window from a bedroom looking directly out on to the gardens has been fitted with a surface that maintains the dignity of the occupant by obscuring the view in to the bedroom without obscuring the view from the bedroom. All windows are restricted and wardrobes including chests of drawers in bedrooms are also secured to the walls. The availability of toilets and bathrooms exceeds the national minimum standard. Although bedrooms are not fully ensuite there are sufficient facilities for service users not to have to share but it is essential that service users are aware of the facilities attributed to their allocated room to ensure that the bathing facility complies with their preferred choice. The cellar is locked and is not available to service users. It is used as a storage area for COSHH products and toilet paper. It also houses the electricity meter and the tumble drier although it is not a designated laundry. The vacuum, although currently broken is kept in the cellar ensuring the need for regular staff access. Therefore it is of concern that the entrance to the cellar i.e. the top of the steps does not have a light and the area was dangerously dark and steep. This should be remedied to minimise risk to staff. Gardens are small but sufficient for the number of service users and it was pleasing to see the garden furnished with furniture and the preferred garden games of the service user. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 21 There are no environmental adaptations or equipment e.g. showers and baths are domestic and there are no tracking or hoist / lifts installed. The service user admitted to date has no assessed physical needs to warrant their provision. The smoking policy was not assessed but staff were observed to smoke outside. The home does not have an adequate designated laundry. Soiled items do not have to be carried through food preparation areas. However as the laundry is a small domestic shed big enough to house a domestic washing machine, laundry has to be carried outside and to the rear of the property. It is concerning that this shed used as the laundry does not have hand washing facilities as per Standard 30.3 and action had not been taken to minimise the risk of cross contamination from this. Records and discussion shows that laundry is being handled that is urine soaked. Gloves were available in the ‘shed’ but the home is not using dissolvable laundry bags that would further reduce the risk from infected laundry. The ‘laundry’ does not comply with Standard 30.4, which states that laundry floor finishes are impermeable and that the floor and wall finishes are readily cleanable. The walls and floors are wooden shed walls. Infection control policies and risk assessments to reduce contamination were not available. The home’s Statement of Purpose says that there ‘are facilities for service users to do their own laundry’. However the laundry is not domestic in style and in line with the spirit of ordinary living. It also does not promote good infection control practice. A further concern is that if service users are to be encouraged to do their own laundry the wobbly paving slabs which lead to the laundry shed are a risk and a heightened risk in the winter, wet, ice, snow etc. This risk also faces staff. The Inspector asked the Acting Manager if the Fire Department, Environmental Health and Infection Control nurse are satisfied with the laundry arrangements. This was not known and it is a requirement to seek clarification. Water temperatures of outlets used by service users have been taken and temperatures were largely compliant with the exception of one in bathroom 2 on 12.6.05, which reads 53 degrees. No action had been taken to remedy this although temperatures thereafter were compliant. Only one temperature is recorded for each room, which may house more than one outlet e.g. shower, bath and basin. All water outlet temperatures must be taken, identified and recorded. Fridge and freezer temperatures were concerning and the Acting Manager agreed to take immediate action. The fridge was recorded as freezing. Whereas the recorded freezer temperatures were significantly too warm at minus 8, minus 9 and minus 10 degrees for the whole period between 22 May 2005 and 17.6.05. This if the readings were correct food poisoning is a risk. Staff must be supported to understand how to take the readings, know the correct and acceptable temperature ranges for the fridge and freezer and must Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 22 take appropriate action if readings do not comply e.g. report to manager, keep under review, transfer food if safe to do so, discard food held in non-compliant temperatures for too long, call fridge engineer and record all action taken to evidence due diligence. Most safety maintenance certificates were available and were in date e.g. the following was seen: chlorination and bacteriological certificates for the water supply, 5 year total electrical installation test certificate, portable appliance tests, gas landlords annual safety certificate and in house tests are undertaken appropriately in respect of fire safety systems. The gas boiler has been boxed in and although it is furnished with ventilation holes the Inspector asked the Acting Manager to check with a Corgi approved company that this complies with safety regulations. A fire drill had been carried out on 23.5.05 where 5 staff were recorded as having taken part. The Acting Manager must ensure that all staff takes part in a regular fire drill. There is a certificate to evidence the installation of the fire alarm system and emergency lighting system in November 2004. However there was no evidence of a service contract being in place to ensure the regular service of this fire system and there was no evidence that it or the fire extinguishers had been routinely serviced since their installation. A security risk assessment for the premises must be undertaken with control measures put in place to control any risk identified. A fire risk assessment is not in place and was subject to immediate requirement. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 23 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 Shortfalls in staffing ratios at night for 4 nights following admission of the first service user put staff and service users at risk. Insufficient recruitment checks for the majority of the staff group including the Acting Manager also has compromised the safety of the service user admitted to the home. EVIDENCE: At the time of inspection there was one service user accommodated, who is assessed as needing a staffing ratio of 1:1 with 2:1 ‘at times that are difficult to predict’. The Acting Manager informed the Inspector that therefore 2 staff are on duty day and night to support this one service user. Two staff were on duty on the day of inspection but during the morning this included the Acting Manager as a staff member had taken a days annual leave. The Inspector examined the rota and could see that the staffing ratio was being maintained but that in fact it had not been maintained for the 2nd, 3rd, 4th and 5th night of the service users admission to the home on 1st June 2005 when there had been only one staff member, a senior on duty. This was because not enough junior staff had been recruited to cover the night shift at the point that the service user was admitted. This is an unacceptable risk given the identified diagnoses and behavioural needs of this service user combined with the unknown effect of the transition on him. An additional concerning factor is that a lone working policy could not be located combined with the facts that fire training, a fire risk assessment and challenging behaviour training had not Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 24 been provided. Two night staff have been provided for the remaining time which is an acknowledgement of the need for this level of care. A second new service user is being considered for admission. The Acting Manager is aware that this person will need 2:1 staffing. The Manager said that it is envisaged that the manager post will be supernumerary to care staffing ratios, which is good practice. The home does not have bank staff and the Inspector was told that it is company policy not to use agency staff. The Inspector requires written confirmation of contingency arrangements to cover vacant shifts. Recruitment checks are insufficient placing service users at risk. Beaconhurst is a new service and all staff have been recruited between March and June 2005. Seven out of 12 staff do not have Criminal Record Bureau and Protection of Vulnerable Adults checks. Only 3 staff have a POVA first check and a CRB. Two staff have a POVA first check only. Where the Inspector was informed that CRB checks have been sent for there is no evidence of this. No risk assessments have been undertaken and the Commission for Social care Inspection has not been informed of any extenuating circumstances or the intention to appoint without appropriate checks. All staff were appointed prior to the admission of the first service user who was admitted to the home on 1.6.05. There is no CRB or POVA check in place for the Acting Manager. Whilst there is some identification in respect of her on file, a copy of the birth certificate and passport were not available. She said that she has not received a copy of a CRB check at her home address indicating that one has not been sent for. She was employed in February 2005. Staff member 1 started in post on 30 May 2005. A CRB has not been obtained or sent for in respect of him, as he has not produced identification. A POVA first has not been obtained. There are 4 significant gaps in employment which are explained by the applicant. Permission has been given by the applicant to approach his GP but action to ensure the physical and mental health of the applicant has not been taken. A second staff member who has a CRB has a previous disclosure on the CRB. No action has been taken in respect of this. The CRB is dated after employment commenced. There is a POVA first check but it is dated after employment commenced. The home did not accommodate a resident until 1.6.05, which was after receipt of these checks, which indicate a concern that required investigation. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 25 References cannot be authenticated for the third staff member whose personnel file was sampled by the Inspector, as there is no name, address, signature of the referee and no date on the references. Identification for staff member 3 was not on file but was produced by the Acting Manager. This staff member has not completed the self-declaration in respect of previous criminal history on the application form as required. A CRB undertaken by a previous employer has been relied upon and the providers have not undertaken their own CRB check. CRB’s are no longer portable. The Protection of Children from Abuse list and not the required POVA list for working with vulnerable adults has been included in this portable CRB. This is inappropriate on two counts. The CRB and POVA checks for staff member 4 were both obtained 2 months after employment commenced. A service user was not admitted until 1.6.05 after receipt of the checks. However, the first written reference is a personal reference from a friend who he has known for 5 months. There is no name, date or address to authenticate this reference. Someone who has known him for only a short period of time again provides the second reference. The reference indicates that it is a personal reference but is indicated on the application form as an employer. The name of the business is not however provided. The designation of the referee is not clear. This reference indicates a previous concern. The applicant has given written permission to approach his GP but action again has not been taken to ensure physical and mental fitness for role. As above recruitment checks were found to be insufficient and unsafe. The recruitment policy is inadequate to support appropriate practice. The policy is dated 26 October 2004 and says that ‘no candidate must start until at least verbal references are sought’. This is misleading. It further refers to ‘checks considered appropriate’. Checks required by regulation are not specified and there is no further guidance in terms of undertaking all regulatory checks prior to appointment. Seven out of twelve staff currently working with the service user admitted two weeks prior to this inspection did not have a CRB or POVA check. Immediate requirement was issued to ensure the immediate safety of the service user and to ensure that appropriate checks are obtained. All checks must be obtained prior to the employment of all staff members. The Managers and Proprietors viewed the findings seriously and the service user was temporarily moved to another company home on the day of inspection and with Social Services knowledge, to give time to ensure all checks are sufficient. It was intended to enable those staff with sufficient checks to work with him in the new environment. The Inspector advised the management to ensure that a regulation 37 notice was supplied to the office of the Commission for Social Care Inspection responsible for the home temporarily accommodating the service user. This Inspector was assured that this was in hand. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 26 Staff had all been appointed prior to the service users admission to the home. Service users should be supported to be involved in staff selection and the revised recruitment policy and procedure should address this for future recruitments. A contract of employment was available for only one of 5 staff sampled. Job descriptions were not available. There was one copy of the General Social Care Council Code of Conduct available within the home. Individual copies have not been issued but the Acting Manager was aware of the need for this. Staff must sign for its receipt and this signature must be held on their personnel files. Training was not fully assessed but the following training needs were identified: Fire, challenging behaviours and physical intervention, autism. Induction training for new staff is not sufficient. It appears that the home is only geared to providing its own in house induction and performance with this was inconsistent. A staff member who commenced employment in March had almost finished induction with recorded evidence of knowledge and understanding. Another staff member appointed at the same time had completed in house training. Another two staff member who commenced employment after this had not started but one verbally confirmed having been appraised of policies and procedures and fire safety etc. Learning Disabilities Award Framework induction is not being completed and a plan of action to provide induction training to the required Standard and within the required timescales is included in this report as a requirement. Other mandatory training was not assessed at this inspection. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 27 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 There is some evidence of adherence to safety considerations but patchy performance does not sufficiently minimise risk to adequately protect service users and the safety of service users is compromised. EVIDENCE: Evidence is described under the environmental standards. In addition the Inspector found COSHH products unlocked in a lockable cupboard. The Acting Manager said that the cupboard is normally locked. A fire risk assessment was not in place and fire training had not been provided at all for staff who had been recruited between February and June many of whom were new to care and one of whom was 18 on the day of inspection. This was subject to an immediate requirement notice. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 28 The combination of environmental factors, inadequate recruitment and insufficient night staffing provision for a newly admitted service users whose behaviours were unknown at an uncertain time of change for him, and lack of training to equip staff, provide concern about the home’s performance with respect to safety and provides scope for urgent improvement. The home’s Registered Manager left his position early into his appointment and the Deputy Manager, who intends to apply for registration, is managing the home on an acting basis. It is important that an application is submitted without delay. Nobody is acting into the Deputy Manager Post and whilst the Acting Manager said that all the seniors are supporting her well, this is a vacancy that requires attention in order to comply with the staffing structure as per the home’s Statement of Purpose. This was the Acting Managers first inspection and she remained positive and calm in spite of the disappointment and stress arising from some of the more serious concerns identified, acknowledging the learning opportunities. The Acting Manager said that she has 11 years care experience and although she has NVQ 2 (certificate seen) is mindful of the need to obtain NVQ 4 and a management qualification (Registered Managers Award). She has achieved the Appointed Persons First Aid certificate and this is valid until 2007. Staff spoken to spoke highly of her describing her as approachable, supportive and that she makes sure things are done. Policies and procedures were not assessed in their entirety. The recruitment policy seen does not support service users best interests and the contract of residency does not wholly support this either. There didn’t appear to be an infection control policy or a lone working policy and if these are available corporately they were not located on the premises. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 29 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x 2 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 4 3 3 1 Standard No 11 12 13 14 15 16 17 x 2 2 x 2 x 1 Standard No 31 32 33 34 35 36 Score x x 2 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beaconhurst Score x 1 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 30 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 YA1 Regulation 4, 16 Schedule 1 Requirement The Statement of Purpose must be reviewed to ensure that it includes all of the required information. (Omissions identified are fees charged, what they cover and the cost of extras, the amount of communal space available per service user and whether this does not meet, meets, or exceeds the National Minimum Standard. Staff qualifications stated must be verified.) Timescale for action 31.8.05 2. YA1 5, 16 3. YA5 5(c) (Requirement made from Inspection June 17th 2005) The Service User Guide must 31.8.05 include, average communal space available per service user and must be in an accessible format for service users. (Requirement made from Inspection June 17th 2005) The service users contract of 31.8.05 residence must be reviewed to include the stated fee, a 12 week trial period, an identified room number (removing the home’s right to move service users to alternative rooms and the service users right to use Version 1.30 Page 31 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc 4. YA6 5. YA6 National Health facilities without charge) (Requirement made from Inspection June 17th 2005) 15, 12, 13 The care plan must be adjusted to ensure the time scale is specifically stated i.e. 3-month blood tests Staffing ratios assessed as required for 24 hours must be stated on care plan (Requirement made from Inspection June 17th 2005) 15, 12, 13 Care plans must also include routine health screening such as dentist, chiropodist, and optical checks, hearing checks and for men testicular screening. 31.7.05 31.7.05 6. YA12, 13, 14 16(2)(n) These checks must be planned for and actionned annually as a minimum. Expressed food likes and dislikes of service users must be assessed and recorded (Requirement made from Inspection June 17th 2005) The acting manager is required 31.7.05 to ensure that a recorded programme of activity is agreed with the service user where possible, based upon preferences and wishes. This programme of activity must be monitored, evidenced and kept under review. (Requirement made from Inspection June 17th 2005) Links with family and friends must be assessed and included in a plan of care in accordance with the service users expressed and recorded wishes. This must be implemented and kept under review. (Requirement made from Inspection June 17th 2005) 7. YA15 16(2)(m) 15 31.7.05 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 32 8. YA17 13(4)(c), 15, 16(2)(i), 17(1)(a) Schedule 3(3)(m) To ensure that weights are taken and recorded regularly. To undertake a nutritional risk assessment and develop a care plan to meet nutritional needs of service user identified in letter of 22 June 2005. The care plan must be kept under regular review with the review evidenced. The advice of a dietician must be sought. Action taken and outcomes must be confirmed in writing to the Commission for Social Care Inspection by 24 June 2005. (Requirement made from Inspection June 17th 2005) Fresh milk must be available within the home at all times and supplied to meet the assessed nutritional needs of each service user e.g. skimmed, semi skimmed and / or full fat. Fresh food products must be available e.g. milk, meat, vegetables. (Requirement made from Inspection June 17th 2005) Quantity of food eaten must be recorded in the food intake records. (Requirement made from Inspection June 17th 2005) Paving in the external grounds must be made safe. (Requirement made from Inspection June 17th 2005) Bedrooms must be furnished with all facilities listed under Standard 26.2 unless there is a clear documented reason for not Immediate 9. YA17 16(2)(i) 30.6.05 10. YA17 11. YA24 13(4)(c), 15, 16(2)(i), 17(1)(a) Schedule 3(3)(m) 13(4) 23(2)(o) 16(2)(c) 30.6.05 31.8.05 12. YA26 31.7.05 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 33 13. YA30 13(3) doing so based upon risk assessment. (Requirement made from Inspection June 17th 2005) An Infection Control Policy must be held on the premises (Requirement made from Inspection June 17th 2005) The ‘laundry’ facility must be reviewed in conjunction with advice from the Infection Control Nurse and / or the Environmental Health Department and any required action communicated in writing to the Commission for Social Care Inspection with target dates. A risk assessment to minimise the risk of cross infection must be developed and adhered to. Hand washing facilities must be provided in the ‘laundry’ (Requirement made from Inspection June 17th 2005) Fridge and freezer temperatures must be maintained within the acceptable safe range and action must be taken and recorded where none temperature compliance is identified. (Requirement made from Inspection June 17th 2005) Written confirmation of contingency arrangements to cover arising vacant shifts must be provided to the Commission for Social Care Inspection. (Requirement made from Inspection June 17th 2005) Staffing ratios must be maintained at all times. (Requirement made from Inspection June 17th 2005) To take appropriate action to minimise risk to service users 31.7.05 14. YA30 23(5) 13(3) 31.8.05 30.6.05 15. YA30 13(3) 17.6.05 16. YA33 18(1)(a) 31.7.05 17. YA33 18(1)(a) 17.6.05 18. YA34 19 Immediate Page 34 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 from inadequate recruitment checks with immediate effect and to communicate this in writing to the Commission for Social Care Inspection by 21 June 2005. To ensure that all checks as per Schedule 2 are in place for all staff (including the acting manager)and to confirm in writing to the Commission for Social Care Inspection as to action taken by 21.6.05 (All appropriate checks, references, documentation and identification must be in place prior to the appointment of new staff from the next appointment) (Requirement made from Inspection June 17th 2005) Systems must be in place to ensure that it is possible to authenticate written references(Requirement made from Inspection June 17th 2005) Appropriate action must be taken where checks indicate previous criminal offences 19. YA34 19 17.6.05 20. Ya34 19 17.6.05 21. YA35, 6, 23 13(6), 13(7) (Requirement made from Inspection June 17th 2005) To book appropriate training in Immediate managing behaviour and physical intervention and confirm the date booked to the Commission for Social Care Inspection. Action must be taken to minimise any risk prior to training. This action taken must be confirmed in writing to the Commission for Social Care Inspection. Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 35 22. YA35 18(1)(c)(i ) 23. Ya35 18(1)(c) 24. YA37 9 25. YA40 19 Appendix 2 (Requirement made from Inspection June 17th 2005) Training for all staff must be booked for the following by the date given: Autism Awareness: including models of care included in the home’s Service User Guide e.g. TEACCH, PECS, MAKATON (Requirement made from Inspection June 17th 2005) The provider must confirm in writing to the Commission for Social care Inspection an action plan to ensure that induction and foundation training is provided to the required standard (LDAF) and within the required timescales (Requirement made from Inspection June 17th 2005) The provider must ensure that an application for Registered Manager of Beaconhurst is submitted to the Commission for Social Care Inspection by the date set. (Requirement made from Inspection June 17th 2005) To review and amend the homes recruitment policy and procedure to cover all areas of recruitment required by regulation to ensure appropriate guidance. A revised copy of the recruitment policy and procedure must be provided to the Commission for Social care Inspection by Friday 1st July 2005. Care Homes Regulations 2002 Regulation 19, Appendix 2 (Requirement made from Inspection June 17th 2005) A Policy on Lone Working must be developed / available and a 31.7.05 31.7.05 31.7.05 immediate 26. YA41 (34) 18(1)(a) 31.8.05 Page 36 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 27. YA42, 35 13(4), 23(4)(d), copy supplied to the Commission for Social care Inspection. (Requirement made from Inspection June 17th 2005) Fire training for all staff must be booked and the date of training and names of nominees confirmed in writing to the Commission for Social Care Inspection by 24 June 2005. Confirmation of attendance must then be confirmed to the Commission for Social Care Inspection in writing following the training. Care Homes Regulations 2002 Regulation (Requirement made from Inspection June 17th 2005) A detailed fire risk assessment must be undertaken and a copy provided to the Commission for Social Care Inspection by 24 June 2005. (Requirement made from Inspection June 17th 2005) The provider must confirm in writing to the Commission for Social care Inspection that the West Midlands Fire Service has verified the appropriateness of the locking mechanism to the front door. Immediate 28. YA42 23(4)(a) 13(4) Immediate 29. Ya42 23(4)(3)( c) 31.7.05 30. YA42 13(4) 23(5) 31. YA42 13(4) (Requirement made from Inspection June 17th 2005) The use of the wall mounted gas 31.7.05 heaters in bedrooms must be risk assessed and action taken to minimise any risks identified seeking the advice of the Environmental Health Department. (Requirement made from Inspection June 17th 2005) The Acting Manager must seek 30.6.05 Version 1.30 Page 37 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc 32. YA42 13(4) 33. YA42 13(4) 34. YA42 23(4)(c)(i v) the written approval of a Corgi Registered gas service engineer that the action taken to box-in the gas boiler meets safety regulations. (Requirement made from Inspection June 17th 2005) A risks assessment must be undertaken in respect of the ground floor bedroom that houses a thumbscrew locking mechanism on an external door that opens into the garden. (Requirement made from Inspection June 17th 2005) All water outlet temperatures must be taken, identified and recorded with recorded action taken where temperatures are found not to comply with the recommended range. (Requirement made from Inspection June 17th 2005) The Acting Manager must ensure that a service contract is in place to ensure the regular service of this fire system including alarm, emergency lighting and fire extinguishers and that routine services are appropriately carried out with evidence available for inspection. (Requirement made from Inspection June 17th 2005) A security risk assessment for the premises must be undertaken with control measures put in place to control any risk identified. (Requirement made from Inspection June 17th 2005) All COSHH products must be appropriately stored. (Requirement made from Inspection June 17th 2005) Insurance certificate displayed Prior to the occupation of the room. 30.6.05 30.6.05 35. YA42 13(4) 31.7.05 36. YA42 13(4) 17.6.05 37. YA43 25(2)(e) 30.6.05 Page 38 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 must be valid and up to date. (Requirement made from Inspection June 17th 2005) 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. Refer to Standard 24, 42 Good Practice Recommendations The cellar steps should be fitted with lighting for the safety of staff and a risk assessment implemented in the meantime. (Recommendation made from Inspection June 17th 2005) The Provider should consider appointing an Acting Deputy Manager to support the Acting Manager. (Recommendation made from Inspection June 17th 2005) 2. 33, 37 Beaconhurst E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 39 Commission for Social Care Inspection Mucklow Office ParkAddress 1 West Point, Mucklow Hill Halesowen B62 8BR National Enquiry Line: 0845 015 0120 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 E55 S62601 Beaconhurst V227320 170605 Stg4.doc Version 1.30 Page 40 - 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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