Inspection on 02/12/05 for Beaconhurst

This inspection was carried out on 2nd December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 49 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 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 Deborah Sharman Unannounced Inspection 09:45 2 December 2005 nd Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 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.V267963.R01.S.doc Version 5.0 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.V267963.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beaconhurst Address 1 Gorge Road Sedgley West Midlands DY3 1LF 01902 82575 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 Yvonne Williams Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th June 2005 Brief Description of the Service: Beaconhurst House is a newly registered independent 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 DS0000062601.V267963.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the second statutory inspection to have taken place since this new care home began operating. This inspection was unannounced meaning that prior notification was not given so the manager and staff were not able to prepare. The plan for the inspection was to assess those key standards which were not assessed at the previous inspection. It was also planned to reassess recruitment processes due to previously identified considerable concern about practice when recruiting new staff. It was also planned to assess as many previous requirements as possible to judge progress made following the last inspection. This plan was compromised to some degree by extended time taken assessing systems in place to safeguard service users money. Therefore ten previous requirements were not assessed. The remaining previous requirements were assessed and ten are judged to be fully met and have been deleted from this report. The inspector was able to interview a new staff member in detail. Discussion centred on the Standards being assessed and enabled the Inspector to judge staff knowledge and how the home has supported this new staff member. The home has since the last inspection admitted a new service user. Service users were not directly included in the process of inspection as it was felt not to be appropriate as unannounced strangers raise service users anxiety levels. However the Inspector discussed with the manager the possibility of preparing service users for involvement prior to the homes next announced inspection. Both the registered manager and newly appointed Deputy Manager supported the inspection throughout the day, which began at 9.45am and concluded at 5.45pm. The home now has 49 requirements, which is an unacceptable number for a small home and currently accommodating two service users. What the service does well: Beaconhurst welcomes new service users who settle into their new home (which is homely, spacious and domestic in style) well. A new staff member demonstrated good knowledge of a range of subjects including service users privacy, dignity, personal care, rights and responsibilities, choices, decision-making, abuse and protection. Daily routines are generally maintained in accordance with the wishes and preferences of service users and their individuality is known and respected. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 6 A staff member feels that the home succeeds in helping service users to live as independently as possible. The staff member said that service users and parents and families are welcomed and that management support is available to both service users and staff. The Manager and her Deputy manager worked positively with the Inspector throughout the inspection day and responded well to constructive feedback. What has improved since the last inspection? What they could do better: Significant concerns were again identified at this inspection with immediate requirements issued to ensure urgent improvement to safe guard service users. The provider and manager are not ensuring that service users monies are appropriately accessible to the service user or safeguarded. Written guidance, accounting and practice is seriously inadequate and investigations are required where calculations show an unaccounted shortfall in a service users money. Similarly a service user must be reimbursed by the home for inappropriate expenses incurred that should have been met by the home. Financial systems are not open, transparent and accountable and the provider has not given the Manager sufficient guidance or audited systems to assess current practice. The provider has therefore been complicit in poor practice. Whilst recruitment practice has generally improved there remains areas of weakness. Where Criminal Record Bureau checks have indicated a concern in a person’s criminal history the manager and provider have not responded to this and no action has been taken to ensure that service users are appropriately protected. This has previously been identified and pointed out as requiring improvement. Similarly staff have been recruited prior to receipt of a Criminal Record Bureau check (but with a POVA first check) without being able to demonstrate extenuating circumstances to justify this. Risk assessments in relation to recruitment undertaken do not assess level of risk or make proper Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 7 provision for the control of risk. For example an unchecked staff member is administering medication unsupervised and a staff member not allowed to provide personal care due to her age has been allowed to administer and sign for medication. Environmentally action has not been taken as previously required to prevent risk to service users from scalding and from food borne illness due to food being stored at inappropriate temperatures. The Inspector identified some concern from the records of staff understanding of the causes of behaviour. It would appear from the records of incidents that staff may at times be escalating rather than diffusing behaviour. Although training has been provided as a result of immediate requirement, the Manager and Deputy Manager share the Inspector’s concern about the effectiveness of the learning gained from this. Staff knowledge is also not effectively supported by written guidance. Adult Protection training, which is core training, has not been provided and is not planned. Policies and procedures in relation to behaviour and violence and aggression are inadequate. A staff member said that ‘training needs to improve for staff’. 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 DS0000062601.V267963.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. A previous requirement to improve the Statement of Purpose has been partly met. The requirement in relation to the Service User Guide has not been met. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Care planning does not support care staff to help service users make decisions. EVIDENCE: Evidence shows mixed performance in respect of decision-making. A staff member had a good understanding of how to enable service users to make decisions about their lives and she was able to give some good examples of how she has put this in to practice. Evidence outlined under Standard 23 shows examples of where choices made by a service user and not respected by another staff member contributed to the escalation of behaviour due to dissatisfaction with service that the service user could not in any other way articulate. In the case referred to, the service user had wanted a cup of tea and was denied one because of cleaning duties. Decision-making is not currently included in care plans and although behaviour plans are in place the inclusion of decision making in the care plan will work to avoid a repeat of this example. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 16 Service users rights and responsibilities are generally respected and outcomes are generally good. Improved care plans which outline decision making and specific choices will better guide staff to appropriately support service users. EVIDENCE: A staff member provided good evidence of how each element of Standard 16 is met which was confirmed during interview with the Manager. For example both told the Inspector that service users mail is sorted in the office, given unopened to the service user and help with reading is provided where required. Care plans do not currently provide guidance on mail management, key holding and responsibility for household tasks. Staff address one service user using an abbreviated form of his surname. The staff member interviewed was able to clearly explain how she knew that this was in accordance with his wishes, which must be recorded on his plan of care. Whilst the home’s policy on pets is included in the Statement of Purpose a separate policy is not available where staff would expect to find it. A service user has requested a pet scorpion and a decision in line with the pet policy and with the outcome of assessed risk must be made and discussed with the service user. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 18, 20 Service users are receiving flexibly provided support with personal care. Medication is generally well managed with systems generally in place to support good practice. Some anomalies however were identified and require improvement for the greater protection of service users. EVIDENCE: A staff member was able to provide good evidence for how each element of Standard 18 is met. She showed good understanding of the principles of privacy and dignity and the particular needs and preferences of individual service users. Records show that service users personal care needs are being met and that their personal choices are implemented e.g. bath instead of a shower. Times when service users have refused aspects of personal care are also recorded which is good practice. Service users are fully mobile and do not require staff or technical support. Service users were both still in bed when the Inspector arrived to undertake the inspection with both rising at different times. Whilst personal care needs have been well assessed it remains for the manager to ensure that assessed needs are included in detailed plans of care for all aspects of each service users personal care. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 13 Medication is generally well managed. The policy guiding practice is robust. Medication is ordered and received in to the home in accordance with recommended safe practice. The home has a medication cupboard that complies with the recommended standard, is bolted to the wall and was observed to be kept locked. Minimum supplies are retained on the premises and no controlled drugs are managed. The care plan contains an up to date record of medications prescribed that tallied with the medication administration record. Medication administered ‘as required’ to manage behaviours had not been used for either service user for some time and is certainly not being overused. Written guidelines are required to ensure that medication prescribed as ‘as required’ is administered consistently and only according to detailed medical direction. The inspector observed unused stock. A monitored dosage system is being used to minimise risk and staff have received training from the supplying pharmacist. There were no gaps in the medication administration records seen but the Inspector was concerned to note that by 3.45 pm one service user had according to the written record received his 8pm medication. This requires investigation. This inspection found a staff member who is not old enough to provide personal care, administering and signing for medication. It was also found that a staff member who has been employed on a POVA first check and for whom there is not yet a Criminal Bureau Record check is administering medication without supervision. Risk assessments in place to minimise risk from the appointment of staff without a CRB does not include non access to medication as a control measure as required. These practices do not protect service users from the risk of medication errors. A further staff member who has not yet received medication training is however not administering medication which is good practice. The manager said that she has ordered a copy of the Pharmaceutical guidelines and the British National formulary, which will provide additional information about handling, and administration of medicines. Service user photographs, consents to medication and a list of staff authorised to administer medications are not in place and the management team were aware of the need for these. Medication reviews have taken place for both service users. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 22, 23 Systems are not in place to adequately support the service user who may wish to make a complaint. Service users are not sufficiently protected from abuse. A range of policies designed to protect service users are inadequate and fail to provide staff with sufficient guidance. Service users finances are being mismanaged. Evidence indicates that staff do not sufficiently understand the causes of behaviour that challenges. This does not prepare them to take appropriate action to meet the needs and choices of service users and risks the dignity, safety and opportunities available to the service user. EVIDENCE: The Complaints procedure contains clear steps as to what to do in the event of a complaint and the timescales for resolution of complaints exceeds that expected by Minimum Standard. Guidance is not clear however if the complainant wishes to contact Head Office or external agencies as contact details were not included but were later found on a different document. The complaints procedure is not in an accessible format for service users and it is not publicly displayed within the home. The Inspector was told that the home has not received any complaints but a complaints log is not available for this to be verified. A new staff member showed a good understanding of her role in the event of her becoming aware of the dissatisfaction of a service user, relative or member of the public. Adult protection is an area identified for significant improvement. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 15 Local multi agency procedures were on the premises to support action in the event of an allegation / incident. However the homes own adult protection procedure is insufficient. It is generally compatible with the spirit of new procedures but there are significant omissions. There is for example no reference to referring staff to the POVA list where there is a concern about the risk that staff member may pose to service users. Referral in the event of an incident to the Commission for Social Care Inspection is also not included. Guidance around the issue of a service users consent and non consent to action in the event of an allegation of abuse is at times misleading and not clear. Guidance must state that action must always be taken even in the event of non consent. The home would benefit from a quick reference guide on the wall, which clearly outlines steps to be taken in the event of an incident or allegation of abuse. Planning and decision making processes in the event of abuse / allegations are not clearly outlined in written guidance. The homes policy on Violence and Aggression does not provide appropriate advice about the causes of behaviour. The reasons given for behaviour that challenges pathologises the individual as ‘sick’ rather than exploring environmental factors including the impact of staff approaches. The restraint policy advises that restraint should be time limited and used as a last resort but does not refer staff to use only those techniques subscribed by training. Records of behaviour incidents demonstrated limited staff understanding of the causes of behaviour, needs and preferences of service users or diffusion techniques. Records also did not evidence that rights and choices were being respected and there was no understanding of the definition of restraint Adult protection training has not been provided and had not been planned. This must be a priority. Written guidance to assure staff action in the event of gifts being offered to them by service users could not be located and was assumed not to exist. Guidance on staff involvement in wills is included in the financial policy but would benefit from being available separately as the manager was not aware of the location of such guidance. Inventories of possessions were not completed for the newly admitted service user and were only partially complete for the other service user. Inventories must be fully completed on the day of admission. Financial policies and procedures for the management of service users finances are insufficient and fail to operationally guide managers and staff. Financial systems and practice in relation to the management of service users finances are insufficient and not transparant. This is failing to protect service users financial interests and failing to protect staff and managers. Discussion with a Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 16 staff member showed some uncertainty about who funded staff expenses in the community and reviewed policy must make this clear. One service user’s money is not accessible to him. He does not have a bank account and between July and November had access to no money. There is no record of any financial activity for him between 14 July 2005 and 1 November 2005. When money has been made available to him it has been done so inappropriately in such a manner that does not protect the service users interests. It is concerning that unacceptable financial practices continue following a letter (from the Commission for Social Care Inspection) to the provider on 13th September 2005 pointing out the inappropriateness of making petty cash payable in a personal cheque to the manager. Assurances were received in writing by the Commission for Social care Inspection from the provider that this practice had ceased. The practice of providing service users money in this manner is viewed even more seriously. The service user meanwhile has only £5.03 available to him which will negatively impact upon his quality of life. He has no money available to fund Christmas. Financial records are insufficient and do not fully account for expenditure on service users’ behalf. The manager is not regularly checking transactions and the financial mismanagement has not been identifed during regulation 26 visits. Monies received are not recorded as received. A running balance has not been kept to reconcile against cash in hand. Calculations on the day of inspection showed that £24.82 belonging to a service user was missing and unaccounted for. Inspection of receipts shows that a service user has been regularly and inappropriately funding meals, food, pop, milk and tea bags. The Inspector was told that the receipted meals funded meals that the home is contracted to provide as part the contract fee. From the receipts it would appear that the service user has also funded meals for other unknown third parties. Records were examined at inspection to indicate whether the third party was a second service user or a staff member. Food intake and shift records had not been completed for the appropriate date and were therefore insufficient and conclusion could not be drawn. This requires further investigation. There is not a system in place for staff to appropriately check monies at handover. The home does not have a working safe and service users money is being stored in an unlockable drawer. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 17 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 the following standard(s): 24 Temperature none compliance in respect of water and food storage is risking the safety of service users. EVIDENCE: This Standard was not fully reassessed at this inspection but was sufficiently assessed to make a judgement about food and water temperature safety compliance. Most previous requirements in relation to the environment were not assessed although it is noted that an Infection Control Policy is now available on the premises as required. Water outlets are not regulated and whilst temperatures throughout November were largely compliant temperatures were excessively hot at water outlets directly accessible to service users on 26 November 2005. This sudden and unexpected change in temperature poses a particular risk of scalding and it is of concern that action was not taken. Freezer temperatures were also providing a high risk of food borne illness as Novembers records showed temperatures to be consistently too warm at minus ten degrees. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 Recruitment processes are better but not fully protecting service users. Training levels have improved since the last inspection with some training having been undertaken and more planned. EVIDENCE: Whilst recruitment practice has generally improved there remain areas of weakness. Where Criminal Record Bureau checks have indicated a concern in a person’s criminal history this has not been actionned by the manager and provider and no action has been taken to ensure that service users are appropriately protected. This was identified for improvement previously. Similarly staff have been recruited prior to receipt of a Criminal Record Bureau check (but with a POVA first check) without the manager being able to demonstrate extenuating circumstances to justify this risk. Risk assessments undertaken do not assess the level of risk or make proper provision for the control of risk. For example an unchecked staff member is administering medication unsupervised and a staff member not allowed to provide personal care due to her age has been allowed to administer and sign for medication. However of those staff files case tracked references were available and were authenticated. POVA first checks were in place along with medical checks, appropriate identification and contracts of employment were also present on Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 19 file. There was also evidence that staff had been provided with a Code of Conduct issued by the General Social Care Council. Two staff members have been recently transferred from a company home out of area. The Inspector was unable to assess recruitment processes followed for them, as their personal files were not available on the premises as required. In the time since the last inspection a number of training courses have been provided. All staff have done Food Hygiene training and Fire training. All staff (except 3 new staff) have also done SKIP UK training to support service users challenging behaviour. Three staff have undertaken Makaton training that will positively support a new service user who uses this method to communicate. All staff are enrolled to undertake the Learning Disability Award Framework induction programme. Whilst this is positive it means that none of the staff to date (and most are newly employed and new to Care) have received appropriate induction training within the required timescale. All staff are due to begin NVQ in January 2006 with the exception of one staff member who already holds NVQ 3. The manager has started her NVQ 4 in Care, which she intends to convert into the Registered Managers Award and the Deputy Manager said that he has applied to undertake the Registered Managers Award too. First Aid training is planned although there is no date for this yet. Staff who have previously done it but not received certificates will redo the training. Awareness training in Autism is also in the process of being booked. Adult Protection training has not been provided and is not planned. The home does not have a training plan or matrix to support the strategic provision of training. The management team were aware of the need to do this. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 There is some evidence of self-monitoring but further development is needed to assure service users that they are living in a developing home that regularly seek their views. EVIDENCE: There is some evidence of quality assurance activity. For example the area manager is undertaking regulation 26 visits although records indicate that these are not monthly as required and copies are not being provided regularly to the Commission for Social Care Inspection. The last record received was in August 2005. These visits include comments by service users but have not identified the serious omissions in practice relating to the management of service users finances. The manager is also undertaking monthly audits of the environment and documentation. Neither service user surveys nor feedback from third parties is obtained regularly and published. There is not an action plan in place to make improvements identified from continuous self-monitoring. Many policies and Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 21 procedures require review. Some but most previous requirements assessed have not been met. Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 22 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 x x x x x Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 2 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 2 17 Standard No 31 32 33 34 35 36 Score x x x 2 1 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beaconhurst Score 2 x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x DS0000062601.V267963.R01.S.doc Version 5.0 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 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, 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.) (Requirement made from Inspection June 17th 2005 and not met at December 2005) The Service User Guide must 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 and not met at December 2005) The service users contract of residence must be reviewed to include the stated fee, a 12 week trial period, an identified room number (removing the DS0000062601.V267963.R01.S.doc Timescale for action 31/03/06 2 YA1 15, 16 31/03/06 3 YA5 5(c) 31/03/06 Beaconhurst Version 5.0 Page 24 home’s right to move service users to alternative rooms and the service users right to use National Health facilities without charge) (Requirement made from Inspection June 17th 2005 and not assessed at December 2005) 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 and not assessed at December 2005) Care plans must also include routine health screening such as dentist, chiropodist, and optical checks, hearing checks and for men testicular screening. 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 and not assessed at December 2005) Decision making must be 31/12/05 included in service users care plans and must account for how and what decisions can be made by the service users and what decisions if any are made by others. DS0000062601.V267963.R01.S.doc Version 5.0 Page 25 4 YA6 15, 12, 13 31/12/05 5 YA6 15, 12, 13 31/12/05 6 YA7 12 Beaconhurst 7 YA12 16(2)(n) New Requirement at December 2005. The registered manager is 31/12/05 required 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 and not assessed at December 2005) Links with family and friends 31/12/05 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 and not assessed at December 2005) Care plans must include service users preferred form of address, preferences re mail management, key holding and responsibility for household tasks. New Requirement at December 2005. 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. 8 YA15 16(2)(m) 15 9 YA16 15, 12 31/12/05 10 YA17 13(4)(c), 15) 09/12/05 Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 26 Action taken and outcomes must be confirmed in writing to the Commission for Social Care Inspection by 24 June 2005. (Immediate Requirement made from Inspection June 17th 2005 and not met at December 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 and not assessed at December 2005 but financial records show service user has been funding own milk) Quantity of food eaten must be recorded in the food intake records. 11 YA17 16(2)(i) 05/12/05 12 YA17 16(2)(i) Sch 3(3)(m) 31/12/05 13 YA18 15 (Requirement made from Inspection June 17th 2005 and not met at December 2005.) All aspects of personal care 31/12/05 must be included as guidance in plans of care and must be based upon assessed need. New Requirement at December 2005. To immediately cease as of 2nd December 2005 at 4pm unchecked and underage staff administering medication. To confirm action taken in writing to the Commission for 14 YA20 19, 18, 13(2) 05/12/05 Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 27 Social care Inspection by Monday 5th December 2005 at 5pm. New Immediate Requirement at December 2005. Care plans must include written guidance based upon the prescibers advice that defines when medication prescribed as ‘as required’ is to be administered. New Requirement at December 2005. The registered manager must investigate why a staff member had signed for 8pm medication prior to the time for administration on the day of inspection The outcome of investiogation must be communicated in writing to CSCI. New Requirement at December 2005. The complaints procedure must be in an accessible format for service users. Complaints information must be publicly available and accessible within the home. A complaints log must be available. New Requirement at December 2005. 20(1)(a)(b) The Registered Manager must take comprehensive action to improve financial accounting and accessibility of personal monies to service user (based on all outcomes identified in DS0000062601.V267963.R01.S.doc 15 YA20 13(2) 31/12/05 16 YA20 13(2) 09/12/05 17 YA22 22 31/03/06 18 YA23 09/12/05 Beaconhurst Version 5.0 Page 28 letter to provider dated 3.12.05) To investigate all inappropriate expenditure incurred by identified service user. To also investigate the balance shortfall and take action to make good any and all financial losses incurred by identified service user as a result of inadequate systems. The outcomes of investigations and all action taken and planned must be communicated in writing to the Commission for Social care Inspection by Friday 9 December 2005. New Immediate requirement at December 2005. The provider is required to demonstrate financial transparancy re the receipt of the identified service user’s money into the business account. Independently audited accounts in respect of the identified service user must be provided to the Commission for Social Care Inspection. New Requirement at December 2005. The practice of providing service users monies in a cheque made payable to the manager must cease and confirmation of this must be provided in writing to the Commission for Social Care Inspection by the date given. New Requirement at December 2005 19 YA23 13(6) 31/01/06 20 YA23 13(6) 05/12/05 Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 29 21 YA23 13(6) Financial policies and procedures to guide the safe day to day management of service users finances must be developed and implemented. New Requirement at December 2005 The Registered person must not pay money belonging to a service user into a bank account unless the account is in the name of the service user. Action must be confirmed in writing to the Commission for Social care Inspection by the date set. New Requirement at December 2005 Service users monies must be appropriately stored in safe keeping on the premises. New Requirement at December 2005 The homes Adult Protection procedure must be reviewed. A quick reference guide must be available for managers / staff to follow in the event of an incident / allegation of abuse. The homes policy on Violence and agression must be reviewed to include recognition of environmental triggers on behaviour The homes restraint policy must be reviewed to ensure that it complies with the Department of Healths guidelines on physical intervention and the British Institute of Learning Disabilities Code of Practice. 31/01/06 22 YA23 20(1)(a) 31/12/05 23 YA23 13(6) 31/12/05 24 YA23 13(6) 31/03/06 Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 30 25 YA23 13(6) New Requirement at December 2005 Action (e.g. retraining / supervision/ mentoring etc must be taken where it is identified that there are gaps in staff knowledge re the causes of behaviour that challenges. Staff performance re behaviour management / support must be monitored closely. New Requirement at December 2005 A policy must be developed to guide staff re their involvement in wills and in the event of gifts being offered to them by service users. New Requirement at December 2005 Inventories of all service user possessions must be completed for all service users on the day of admission and must be regularly reviewed and updated. New Requirement at December 2005 Paving in the external grounds must be made safe. 31/12/05 26 YA23 13(6) 31/03/06 27 YA23 13(6) 31/12/05 28 YA24 13(4) 23(2)(o) 31/12/05 29 YA26 16(2)(c) (Requirement made from Inspection June 17th 2005 and not assessed at December 2005) 31/01/05 Bedrooms must be furnished with all facilities listed under Standard 26.2 unless there is a clear documented reason for not doing so based upon risk assessment. (Requirement made from Inspection June 17th 2005 and Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 31 30 YA30 23(5) 13(3) not assessed at December 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 and not assessed at December 2005 although letter from EH to state alcohol scrub sufficient) 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 and not met at December 2005) See new Immediate requirement issued December 2005 – See Standard 42. 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 and not assessed at December 31/12/05 31 YA30 13(3) 05/12/05 32 YA33 18(1)(a) 31/12/05 Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 32 2005) 33 YA33 18(1)(a) Staffing ratios must be maintained at all times. (Requirement made from Inspection June 17th 2005 and not assessed at December 2005) Appropriate action must be taken where checks indicate previous criminal offences (this applies retrospectively where action has not been taken) (Requirement made from Inspection June 17th 2005 and not met at December 2005) Criminal Record Bureau checks must be obtained PRIOR to employment for all new staff unless there are evidenced extenuating circumstances which are demonstrated to the Commission for Social care Inspection. Any person appointed on POVA first check without a CRB due to extenuating circumstances must be subject to full and individual risk assessment and measures implemented to control any identified risk (this applies retrospectively). New Requirement at December 2005 Staff files for all staff employed must be retained on the premises and must be available for inspection. New Requirement at December 2005 Training for all staff must be booked for the following by the date given: DS0000062601.V267963.R01.S.doc 02/12/05 34 YA34 19 05/12/05 35 YA34 19 02/12/05 36 YA34 19 31/12/05 37 YA35 18(1)(c)(i) 31/12/05 Beaconhurst Version 5.0 Page 33 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 and not met at December 2005 - 3 staff done Makaton) 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 (LDAFF) and within the required timescales (Requirement made from Inspection June 17th 2005 and outcome not met at December 2005) All staff must be provided with adult abuse / protection training which must be booked by the date given. New Requirement at December 2005 A training matrix for the staff team and individual staff members must be in place to inform the training programme. New Requirement at December 2005 The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the home. This system must provide for consulation with service users and their representatives. Outcomes of quality assurance reviews must be made available Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 34 38 YA35 18(1)(c) 31/12/05 39 YA35 13(6), 18 31/01/06 40 YA35 18 31/01/06 41 YA39 24 31/03/06 to service users and the Commission for Social care Inspection. New Requirement at December 2005 A Policy on Lone Working must be developed / available and a copy supplied to the Commission for Social care Inspection. 42 YA41 18(1)(a) 31/01/06 43 YA42 (Requirement made from Inspection June 17th 2005 and not met at December 2005) 23(4)(3)(c) 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. 31/01/06 44 YA42 13(4) 23(5) (Requirement made from Inspection June 17th 2005 - not received in writing at December 2005.) The use of the wall mounted gas 31/12/05 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 and not evidenced at December 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 and 45 YA42 13(4) 31/12/05 Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 35 46 YA42 13(4) not assessed at December 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 and see new immediate Requirement issued at December 2005) The registered Manager must take action to protect service users from the risk of both scalding and food borne illness. Water and food storage temperatures must comply with the recommended safe ranges and action must be taken to ensure this. Action taken to immediately protect service users must be confirmed in writing to the Commission for Social care Inspection by Monday 5th December 2005 at 5pm. This must include a target date for the fitting of water temperature valves to all water outlets accessible to service users. Immediate requirement at December 2005. 05/12/05 47 YA42 13(3) 13(4) 16(2j) 05/12/05 48 YA42 13(4) 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 and not met at December 2005) 31/12/05 Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 36 49 YA42 13(4) All COSHH products must be appropriately stored. (Requirement made from Inspection June 17th 2005 and not assessed at December 2005) 02/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beaconhurst DS0000062601.V267963.R01.S.doc Version 5.0 Page 37 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: 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 DS0000062601.V267963.R01.S.doc Version 5.0 Page 38 - 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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