Inspection on 26/06/06 for Beaconhurst

This inspection was carried out on 26th June 2006.

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 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 02/12/05

Beaconhurst 17/06/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Beaconhurst 1 Gorge Road Sedgley West Midlands DY3 1LF Lead Inspector Deborah Sharman Key Unannounced Inspection 26th June 2006 08:45 Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaconhurst Address 1 Gorge Road Sedgley West Midlands DY3 1LF 01902 882575 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Minster Pathways Limited Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd December 2005 Brief Description of the Service: Beaconhurst House is an independent sector Care Home that was registered in the latter half of 2005. The maximum number of service users it can provide care to is three. The service user group is younger adults with learning disability and autism. The home is a converted private residential property located near to 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. The weekly fee charged was not made known to the Commission for Social Care Inspection as requested prior to inspection. However assessment of service users contracts show contracted fees at the time of admission to range from £1780.33 - £1888.00 per week. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced meaning that nobody associated with the home had prior notification of the inspection date and were therefore unable to prepare for it. Two Inspectors carried out this inspection, with one present from 8.45am until 6.45pm and the second Inspector from 9.30am until 5.30pm. The plan for the inspection was to assess compliance with all key National Minimum Standards including progress made towards meeting improvements identified as required at previous inspections. Where assessment at this inspection has shown outstanding requirements to have been complied with they have been deleted from this report. Requirements that have not been complied with remain in this report and new requirements arising from this inspection are indicated as new in the requirement list at the back of this report. Prior to inspection the Commission for Social care Inspection was contacted and a number of concerns were made known. The plan for this inspection was to use this information to focus and the guide the inspection to assess outcomes for service users and to assess the quality of the management of the service. Inspectors used a range of methods to provide them with evidence about the quality of the service provided. A full range of documentation was assessed, care provided to a service user was case tracked, three staff were interviewed as was the Acting Manager and the Operations Manager who arrived in the morning and stayed to support the process of inspection throughout the day. An Inspector also toured the premises. It was not appropriate to interview service users but written feedback had been provided to CSCI from two service users, one aided by his parent to do so. This feedback indicated satisfaction with the service provided. One service user supported by a staff member to provide written feedback said ‘I like the house, the staff are nice, I go to nice places. I like the food’ but ‘sometimes it is noisy’. Comments from a second service user said that the home is ‘comfortable, safe with freechoice’. On arrival at inspection the Inspector was disappointed to find the privacy of a service user whilst bathing was not being promoted. A significant part of the inspection day was spent additionally case tracking systems followed for the proposed admission of a new service user as this was a significant part of the pre inspection complaint. The inspection process was obstructed by misleading information provided to the Inspectors throughout the day resulting in significant delays to the process of inspection. Serious concerns about the quality and integrity of the current management arrangements for the home were subsequently identified. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 7 Since the home opened just over 12 months ago there have been three shortterm managers in post, two of whom became registered with the Commission for Social care Inspection. Outcomes of inspections at Beaconhurst have consistently shown concerns about the quality of the management of the home. This has undermined the stability and development of the home. Outcomes from this inspection cast serious doubt on the integrity and fitness of the Acting Manager and indirectly upon the provider. Inspectors were obstructed in the course of their work by being told lies to cover shortfalls in the homes performance particularly in relation to staffing levels, incidents, availability of money to purchase food on one occasion and, most significantly, the proposed admission of a service user with needs the home was not in a position to meet. Staff had identified these concerns but their concerns were being dismissed. The additional and exacerbating concern was the evidenced pressure the Acting Manager had put on staff to withhold and falsify information to Inspectors. The provider acknowledges that pressure may have been put on the Acting Manager by the organisation to ensure positive outcomes from this inspection and partly attributes this to his behaviour during the course of the inspection. Outcomes such as these promote the self interest of the home and organisation rather than the interests and welfare of service users. Staff chose to ‘blow the whistle’ to the Commission for Social Care Inspection. It is concerning that they did not feel able to initially raise their concerns with the organisation. There is no evidence that the provider was aware of the falsification of records however this lack of awareness casts doubt on the sufficiency of support and monitoring systems made available to the home by the provider. Staff morale is low and two senior staff walked out of their employment shortly before inspection. This was in addition to the loss of a third senior staff member to another of the company’s homes. It was subsequently impossible for the remaining one senior staff member and Deputy manager to ensure a senior presence on all shifts. Rather than address this, energy was put into concealing staff resignations and falsifying rotas. Ultimately it was found that junior staff were staffing some shifts alone with one new and underage 19 year old carer taking responsibility for running the shift alongside a colleague who had been in post for less than a month. This potentially compromises the safety and well being of service users. Two staff have been dismissed and CSCI was not notified as is the homes regulatory duty. Since the last inspection night staffing levels have reduced. The provider cannot evidence the rationale for this and it was not done in consultation with Social Services, the Commission for Social Care Inspection and not based upon risk assessment. There is evidence in staff meetings of this being in relation to ‘pressure on the budget’. Evidence has not been provided to demonstrate that this reduction is safely meeting the assessed needs of existing service users. Omissions and contradictions in care planning and risk assessments do not support staff to adequately meet service user need and minimise risk. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 8 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.V300260.R01.S.doc Version 5.2 Page 9 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.V300260.R01.S.doc Version 5.2 Page 10 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): 1,2, 3, 4, 5 The outcome for this group of standards was judged to be poor. Documentation available to prospective service users and their families is out of date and misleading and therefore does not provide them with an informed choice as to where to live. The needs of prospective service users are not assessed and prospective service users cannot be assured that they will only be admitted if their needs can be met by the home. The intention to prematurely admit one service user is judged to be dangerous compromising both the safety of existing service users, the new service user and staff. EVIDENCE: The Statement of Purpose is a comprehensive document. Fees however are not included in the Statement of Purpose and readers are not informed whether space availability conforms to the requirements of the National Minimum Standards. The document requires additional updating following a significant staff turnover. The document did not make it clear that the named manager is the Acting Manager. The Service User Guide has been translated into widget form. Whether this is accessible to existing service users of the home is debatable and must be kept under review. Evidence within this report demonstrates that the home is not adhering to its own Statement of Purpose in relation to admissions of new service users, choice of home, staffing levels, management and administration, meeting assessed needs, pre placement process etc Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 11 Contracts have been subject to review and now include room numbers to protect service users from unwanted room changes, weekly fees (but not individual’s contributions towards the weekly fee. How service users annual holiday is financed is included but the contract is not in an accessible format for service users. There was very significant concern at this inspection about a proposal to admit a new service user into the homes remaining vacancy. A full assessment undertaken by a person competent to do so was not available. The Acting Manager had not conducted a pre admission assessment either. Care plans and risk assessments for this service user who has complex challenging needs had not been completed. The Acting Manager could not demonstrate the homes capacity to meet the service users needs and in the absence of an up to date assessment there was a lack of clarity as to the nature of the service users needs. Discussion with staff evidenced a high level of anxiety about staff’s individual and collective skills and experience. Staff did not feel sufficiently skilled to meet the service users high level of needs. In addition senior and care staffing levels were inadequate and there was a lack of certainty about required additional staffing levels for the new service user. In spite of this the Acting Manager had arranged to admit the service user on the day of inspection and a contract dated accordingly was in place. The Acting Manager then proceeded to conceal this plan from Inspectors and instructed staff via text message not to discuss the new admission to the home. The proposed Service user had undertaken visits to the home although these were not evidenced. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 12 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): 6, 7, 9 The outcomes for this group of standards was judged to be poor. There are contradictions and insufficiencies in care planning and risk assessments that create the potential for confusion consequently exposing the service users to risk. EVIDENCE: One service user’s care plan or ‘support guidelines’ was inspected. It included guidance in respect of going out on the minibus (2:1 staffing), activities (inc domestic tasks), preparation of meals, bathing and getting up. Behaviour guidelines were also in place and those described were consistent with daily records. Whilst care plans in place are generally consistent with information provided in assessments and review meetings there are however significant omissions in the range of support plans available e.g. no reference to physical health, health screening and how the home plans to meet all the service users social needs. A review date set for the review of the support plans had not been adhered to, plans are not in an accessible format and there was no evidence of family involvement in drawing up the plan although some guidelines are clearly drawn from information supplied by a supporting psychologist. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 13 Care plans also contain detail of things the service user should not do. Without a clear rationale and without a person centred frame of reference these could be seen as restrictions. Multi disciplinary reviews have been held – 2 since the end of 2005 but there were no records available. The case file indicates where decision-making may be compromised due to risk and there is some evidence of involvement of family. There is however no risk assessment or guidelines in place in respect of the management of finances although the contract says the service user is responsible for independently handling their own finances. Other letters on file from financial agents contradict this. Evidence is available from the risk assessments and daily notes that the service user case tracked is supported to take some risks as part of fostering independence. There are a range of risk assessments on file relating to bathing – and the detail correlates to the support plan with the addition of information in respect of risk. The assessment also refers to the need to use a bath mat but discussion shows practice to contradict the risk assessment. Additional contradictions were found. For example a risk assessment for the service user states that staff must supervise eating. But the care plan states ‘do not watch when eating’, as this triggers behaviour that challenges. Contradictions will confuse staff and increase risk to both the service user and staff. Staff had not signed risk assessments to indicate they are aware of their obligation and there was no evidence that risk assessments due for review in March 2006 had been reviewed. Moving and handling risk assessments are in place and are acceptable. However both service users are fully mobile and do not require support to mobilise. Care plans and risk assessments were not in place for a new service user with complex needs due for admission on the day of inspection. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 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 the following standard(s): 11, 12, 13, 14, 15, 16, 17. The outcome for this group of standards was judged to be poor. The provider was not able to demonstrate that systems are in place to ensure that the interests and needs of service users are paramount. Staffing levels to support community activity, some limitations on the availability of the minibus, lack of visual activity plans, a paddling pool rendered unusable through lack of care, omissions in care planning and monitoring and insufficient funds on one known occasion for food support overall judgement. EVIDENCE: Care plan guidelines refer to the service users preferred activities such as domestic tasks and going out in the minibus. Staff meeting minutes on 17/2/06 referred to the need to introduce a visual diary but this had not been developed. The pool in the garden is identified for one service user but could not have been used for a significant period of time given the congealed condition in which the Inspector found it. There were documented activity records seen for the last four weeks. These were not consistent with the record or plan. For example the entry for the 10/6/06 stated as there was no minibus in the afternoon, one service user Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 15 listened to music and sat in garden. CSCI received a complaint prior to inspection alleging that the service users mini bus had been inappropriately unavailable for their use one weekend in June. The care plan for a service user states “ I will ask to go out in the minibus for a drive as this is the most important part of my day”. The activity planner for this time period showed that there was a plan to use the mini bus. Records for the shift that day stated “ X was agitated this afternoon thinking he was due a bus ride just because X was here, he has been left in his room to simmer down”. This is not evidence that this service users needs were met on this occasion. Despite this most of activities provided were consistent with documented assessments and needs. The individual needs of the service user indicate they need to follow fairly rigid routines that limit activities, this is documented and helps to account for deviations from the plan. Based on the service users level of dependency, job opportunities would not be appropriate but there was evidence in personal guidelines that they were involved in some domestic home-based activities when they chose to be. Involvement of the service user in the community is restricted to trips out on the mini bus and attendance at a local sensory centre. There was some reference in the file to the service user having pub visits but how often or when is unclear with care planning and activity planning not being sufficiently robust and accountable in this area. Poor staffing levels do not provide sufficiently flexible staffing to promote good access to community facilities. Cultural diversity issues including religion are not addressed in the care plan. Prior to inspection, within the complaint received by the Commission for Social care Inspection (CSCI) was an allegation that a service users holiday had been cancelled unnecessarily and that the C.S.C.I. had been mislead about the real reason for its cancellation. The Inspector is dissatisfied with the quality of the evidence provided in relation to this cancellation. A letter of cancellation from the holiday company cannot to date be sufficiently authenticated and is important to ratify to confirm the fitness of the provider and positive lifestyle outcomes for the service user affected. There is evidence of contact with family, which is included in assessments, care planning, risk assessments, and contact is evidenced. Staff meeting minutes in February 2006 stated that staff need guidelines for a service user in respect of sexuality. These have not been developed. Systems must be in place to ensure sufficient supplies of food to the home. It was found that due to a shortage of petty cash, a staff member on one occasion had personally funded £40.00 of grocery shopping from a local supermarket. The Acting Manager denied this to the Inspector and the Operations Manager who repeatedly asked him if he was sure of this. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 16 Discussion with the staff member showed that the Acting Manager had been the person to reimburse her from petty cash. A service user has fedback to CSCI that he likes the food available. It was pleasing to see the milk advised by a dietician was available but nutritional risk assessments as previously required have not been undertaken. Weight records are kept however and these presented no concern. Records for food intake are kept but the quality of this record keeping is inconsistent. Guidelines are available to staff but there are some confusing contradictions as indicated under Standard 9. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 17 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, 19, 20. The Outcome for this group of standards was judged to be adequate. Some health screening has been provided. Omissions in some health screening and the management of service users privacy have been identified, and exacerbated by no evidence of action following aborted health appointments. Medication is generally managed adequately but lack of action following a pharmacist’s explicit recommendation to improve the management of medication puts service users at increased risk. EVIDENCE: Upon arrival, the Inspector entered the premises through the side door. This is adjacent to a ground floor bathroom. A service user was having a bath with the bathroom door wide open. No attempt was made to shield the bathing service user from the visiting Inspector. This did not protect his dignity or privacy. From records it is clear that guidelines are available and staff are aware of service user’s need to make their wishes known in respect of which staff support them with personal care on a day by day basis. Guidelines appropriately guide staff in respect of the importance of adhering to service users routines, which is vital for the appropriate management of well being and behaviour management. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 18 Health records show a service user to have been reviewed by a Consultant Psychiatrist and to have successfully had their eyes tested. Outcomes for chiropody and dental treatment are less clear. Dental treatment could not be provided as for one service user as the service user did not cooperate. However guidelines should be in place to support the service user and there is no evidence of whether or how this is to be followed up for the benefit of the service user. A medical practitioner had reviewed the service users medication and medication care plans correlate with medication administration records. Staff administer medication to service users but there is no evidence of consent having been formally obtained. Protocols are in place for the administration of medication prescribed as ‘as required’ which protects service users from the risk of over medication. Stock records for medication not held within the monitored dose system are not in place. It is pleasing to see that the home is receiving support visits from the supplying pharmacist who in May 2006 identified two areas for improvement, neither of which have been implemented. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 19 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 The outcome for this group of standards was judged to be poor. Although there has been some improvement in complaints systems, in practice the home is not being managed in a sufficiently open and transparent manner to assure service users or others that their views will be listened to and acted upon for the benefit, well being and protection of service users EVIDENCE: Action has been taken since the last inspection to improve the complaints systems. There is an improved complaints format for service users and information explaining how to make a complaint is now publicly available within the home. No complaints are known to have been received from service users, relatives or other third parties. Staff however, were using a complaints book to record grievances about not being paid overtime dues, this has now removed. A further book has now been put in place for the recording of any future complaints. There was evidence throughout this inspection that valid staff concerns were not being appropriately responded to by the Acting Manager and staff felt isolated and unsupported. Additionally staff did not feel able to raise issues with higher management. This has lead to staff resigning without working periods of notice. Whilst staff grievances are not complaints the protection of service users is compromised where staff concerns are not addressed appropriately, the proposed admission of a service user prior to there being sufficient staffing levels and training in place as one example. Written local and national guidance available to staff however has been improved along with the home’s own Adult Protection Policy. Policies are also now in place to guide staff response to offers of presents from service users and requests to support service users with will writing. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 20 The management of service users monies has improved since the last inspection and is better, although does not fully protect service users financial interests. The service user case tracked was found to have incurred a £16.80 library fine. Staff have a duty of care to protect the service users financial interests and this should not have been allowed to happen. It is suggested that as a gesture of goodwill that the home reimburses this expense. Up until about a month prior to inspection the other service user was signing the homes records for his financial transactions. No satisfactory explanation could be given for the termination of this. Although service user’s monies are better stored since the last inspection, two staff are not signing for financial activity undertaken on service user’s behalf. The Inspector checked a service users cash in hand against the record of balance and found the cash in hand to be four pence over indicating a small error in financial accounting. Audited records have not been provided to CSCI as required at the last inspection to demonstrate that the financial interests of service users have been protected prior to recent improvements in practice. Two staff have been dismissed but CSCI was not informed by the provider in accordance with their regulatory duty. CSCI has not received any notifications of incidents which adversely affects the well-being or safety of any service user. Disciplinary records were not available on the premises. The Responsible Individual was able to produce disciplinary records for one staff member dismissed and it was noted that a letter of dismissal was not present. Records for the second staff member dismissed could not be produced and therefore the Inspector could not judge how any incident requiring dismissal had affected the well being of service users. Discussion with a new staff member showed they had a good understanding of adult protection issues. She was able to fully define adult abuse and action she would take in the event of becoming aware of any concerns. Behaviour support plans are in place for current service users. It was concerning that this had not been achieved for a service user due for admission on the day of inspection who historically has required a very high level of physical intervention. This staff member also demonstrated a reasonable knowledge of behaviour triggers for one service user and how she would manage escalating behaviour. It was of some concern that the Acting Manager informed the Inspectors that there had been no incidents for one service user in May and June due to an improvement in his behaviour. Discussion with staff showed that there had been many behaviour incidents none of which have been notified to CSCI. Staff were able to locate 14 missing records for this time period in the Acting Managers tray. Incident records available however evidence an improvement in staff intervention and unlike previous inspections there was no evidence of intervention styles escalating situations. There have been no allegations or adult protection investigations. Adult protection training has improved with some training having been provided for some staff in February 2006 and Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 21 records showing that a new staff member new to care had completed this training pre-employment. Training records however are not up to date and require review. The CSCI is aware of a further allegation in respect of the Acting Manager in relation to the use of the homes mini bus. Inspection shows that one service user’s assessed need is for frequent, daily access to the minibus. It is a critical part of his care. Some evidence was available to CSCI to show that the minibus was not available to the service user on occasions. Initial investigation by the provider refutes this and a full report of the investigation and outcomes is required. Failure (as evidenced in this report under Staffing Standards) to provide sufficient staff and staff with sufficient experience and seniority compromises the protection and safety of service users. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 22 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, 30 The outcome for this group of standards was judged to be adequate. The environment is generally designed around the needs of service users and is adequately maintained. Responses to risk management within the environment however are not sufficient and potentially increases risk to service users. EVIDENCE: Improvements since the last inspection have increased service users safety in some respects and these are detailed under Standard 42 within this report. The overriding needs of service users for a safe environment impacts upon the environment and whilst this meets service user need, it detracts from the homeliness of the environment. A service user had pulled down a curtain at one of his bedroom windows. Oneway glass promotes his privacy but lack of a curtain reduces the room’s homely feeling. Mattress protection on the bed of one service user is insufficient with the rubber draw sheet not being fully covered by the cotton overlay compromising the service users comfort. This must be reviewed. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 23 A filled paddling pool rendered unusable by being congealed with algae was on the front lawn by the front door when the Inspector arrived although it was moved during the day. Furniture has been disposed of in the garden and at the time of inspection was awaiting collection in a skip. Wallpaper on ground floor hallways is worn and there is no renewal programme in place for its replacement. The ground floor bath had a small crack with the potential to cause injury and although there was no evidence that a new bath had been ordered the Acting Manager said it was to be replaced that week. CCTV cameras do not work compromising the security of the house. Risk assessments in respect of security previously required were not in place. Service users are mobile and disability equipment is not required. Gas and electric appliances are well maintained and a previous requirement to stabilise wobbly paving slabs outside to the rear of the property has been met providing some improvement in safety measures. The kitchen was clean and the home smells fresh throughout. Food safety systems have improved but infection control requires some improvement. There were no paper towels on the premises as they had run out. Fabric towels were therefore being used which promote rather than reduce the risk of cross infection. The laundry is still a shed. It fails to comply with National Minimum Standards because sluice facilities are not available, walls are not readily cleanable and sufficient hand basins are not considered to be available as per Regulation 23(2)(j). The Environmental Health Department have been consulted who have advised the use of hand sanitizer, as water is not available for staff to wash their hands in the laundry. Hand sanitizer was available in the laundry as recommended by Environmental Health. There are no outstanding requirements in spite of the laundry not meeting Care Homes National Minimum Standards because Environmental Health are satisfied with contingency arrangements. Infection control risk assessments are not however in place. A staff member demonstrated a good knowledge of how to control the risk of cross infection. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 24 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): 32, 33, 34, 35 The outcomes for this group of standards was judged to be poor. Staff recruitment practice is better but still does not fully protect service users. Some training has been undertaken to help staff better meet the identified needs of current service users. The home cannot evidence that it is providing sufficient staff to meet the needs of current service users. Staff have however received an improved programme of training in previous months. EVIDENCE: Staffing levels were seriously inadequate to meet the needs of a service user who was due for admission on the day of inspection. There was not an assessment or care plan available to state required staffing levels but the Inspector was informed that it was believed that he would need a staffing ratio of 3:1 in the community, 2:1 within the home and 1:1 at night in addition to current staffing arrangements. The Acting Manager had told the Inspector that he was in the process of recruiting staff to work with this new service user but that they hadn’t yet been recruited. Assessment of existing staffing levels for the current two service users showed serious shortfalls in staffing numbers following a number of recent resignations. There was also found to be a serious shortfall in senior staff following three having recently left the homes employ. There is also evidence that some staff are frequently working 15 hour days to cover shifts indicating a shortage in numbers of staff employed. One new carer, under 21, had been left in charge of the home with a second worker within the first month of her employment. Staff under the age of 21 must not Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 25 be left in charge of a care home. It is vital that the home has sufficient appropriately experienced and qualified senior staff to support staff to meet the complex and challenging needs of current and proposed service users. Inspection of one service users contract states his staffing requirement to be 1.5 staff from 7am – 10pm. Rotas therefore show with the additional staffing requirements of a second service user that there are insufficient staff on duty over this time period. Contracts show that addition the two existing service users should share 140 night care hours. Night staffing levels have reduced for existing service users since the last inspection also without reference to CSCI, commissioners and without a justifiable rationale or risk assessment. A clear rationale for this could not be evidenced other than by a reference in staff meeting minutes (April 2006) which spoke of ‘blowing the budget’. The provider’s proposal is to increase night staff levels to that in place prior to the earlier decrease on condition that the new service user is admitted. Information available at inspection would indicate that this is not appropriate and safe. This decision is not based upon assessed need and dependency levels. The reduction appears to contradict the assessed needs of current service users who are being funded to share 2 waking night staff. The operational manager felt that the reduction would have been subject to risk assessment but no risk assessment has been undertaken. Staff said that they had been instructed by the Acting Manager to continue to include staff no longer employed on the rota. The Inspector asked the Acting Manager at the beginning of inspection whether there were any staff vacancies. His response was that there were ‘no staff vacancies’. Inspectors were therefore not informed of all recent resignations including those without working periods of notice. Lack of staffing has been disguised by continuing to include staff on the rota who are no longer employed. Appropriate staffing cover is not therefore evidenced on these misleading rotas. Recruitment practice for two staff employed within the previous 3 months was tracked by the Inspector. It was pleasing to see that significant omissions in recruitment practice identified at previous inspections had improved. For example staff had not commenced in employment without the necessary Protection of Vulnerable Adults (POVA) list checks and Criminal Record Bureau (CRB) Enhanced disclosures. However practice in respect of obtaining sufficient and authenticable references and identification must improve. For example sufficient references were not available for both employees and not included on the application form at the point of application. There was furthermore no evidence of interviewing applicants, no evidence of service user involvement in recruitment, no evidence that staff had been issued with copies of the General Social Care Council’s Code of Conduct and no evidence that job descriptions had been provided to ensure staff are aware of their role and Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 26 professional accountability. These concerns were further compounded by insufficient evidence of appropriate induction training for new staff. A new staff member said that she had settled well and had been supported by colleagues. A training matrix and individual staff training profiles have been put in place since the last inspection. New staff now need to be included within this . Records indicate that staff have been provided with a range of training opportunities in the 12 months prior to this inspection. Training undertaken includes Fire Awareness, adult protection, challenging behaviour, Strategies for crisis intervention, food hygiene, and Autism awareness (to help staff understand and respond to the specific diagnoses of service users admitted to the home). Medication training (provided in October 2005) is not accredited. A system is not in place to routinely assess and support staff competence in the administration of medication with no evidence that a newly recruited underage staff member (left to run the shift and administer medication) had been inducted to ensure the correct administration of medicines. None of the staff currently working at the home are yet qualified to NVQ level 2 and staff are not sufficiently trained to meet the dietary or potential behavioural needs of the proposed new service user as guidance was not available (as no care plan was available). The provider states that since inspection it has commissioned alternative training to address this. Compatibility with previously taught training principles and practice must be evidenced to ensure that the approach of the whole staff team to behaviour and physical intervention is consistent and safe. Staff demonstrated their integrity and commitment to the well being of service users by co-operating fully with the inspection process in difficult and compromising circumstances. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 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 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): 37, 38, 39, 42 The outcome for this group of standards was judged to be poor. There was serious concern as to the management of the home. Poor and dishonest leadership has compromised service users interests. Service users views and interests have not underpinned the running and development of the home, which has not been managed openly, accountably and transparently. EVIDENCE: Since the home opened just over 12 months ago there have been three shortterm managers in post, two of whom became registered with the CSCI. The history of inspection and regulation at Beaconhurst consistently has shown concerns about the quality of the homes management. This has undermined the stability and development of the home. In addition outcomes from this inspection cast serious doubt on the integrity and fitness of the current Acting Manager and indirectly upon the provider. Inspectors were obstructed in the course of their work by being told lies to cover shortfalls in the homes performance particularly in relation to staffing levels, incidents, lack of availability of money to purchase food on one occasion Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 28 and most significantly the proposed admission of a service user with needs the home was not in a position to meet. Staff had identified these concerns but their concerns were being dismissed. The additional and exacerbating concern was the evidenced pressure the Acting Manager had put on staff to withhold and falsify information to Inspectors. The provider acknowledges that pressure may have been put on the Acting Manager by the organisation to ensure positive outcomes from this inspection and partly attributes this to his behaviour during the course of the inspection. There is no evidence that the provide was aware of the falsifications but such lack of awareness casts doubt on the providers ability to manage, support, monitor and quality assure the home and the performance of the Acting Manager. Following concerns identified at this inspection the provider put it in writing to CSCI that the Acting Manager would be moved from a Management to a support position. Subsequently it was found that he had in fact been moved not to a support position but to a senior position where he would continue to manage staff and accept responsibility for the home in the absence of the new Acting Manager. Since this concern was raised, the provider has since suspended the Acting Manager and instigated its disciplinary procedure. Staff morale is low and two senior staff walked out of their employment shortly before inspection. This was in addition to the loss of a third senior staff member to another company home. It was subsequently impossible for the remaining one senior staff member and Deputy manager to ensure a senior presence on all shifts. Rather than address this, energy was put into concealing staff resignations and falsifying rotas. Ultimately it was found that junior staff were staffing some shifts alone with one new and underage 19 year old carer taking responsibility for running the shift alongside a colleague who had been in post for less than a month. Two staff have been dismissed and CSCI were not notified as is the homes regulatory duty. Since the last inspection night staffing levels have reduced. The provider cannot evidence the rationale for this and it was not done in consultation with Social Services, the Commission for Social care Inspection and not based upon risk assessment. There is evidence in staff meetings of this being in relation to ‘pressure on the budget’. Evidence has not been provided to demonstrate that this reduction is safely meeting the assessed needs of existing service users. Inspection provided evidence of the Acting Managers lack of understanding in relation to his obligation to meet the needs of service users. In discussion he accounted for his actions saying that he felt obliged to protect the budget and in response to the dietary needs of the new service user felt it would be acceptable for all service users to follow the same specialised diet ‘because it would be easier’. Management outcomes show that the approach of the home is neither open, positive or inclusive. The Acting Manager asked staff to falsify documents and to lie to Inspectors which does not communicate an appropriate sense of Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 29 direction or leadership. Staff approaching CSCI directly demonstrates that there are ineffective strategies for enabling staff within the home to voice concerns and affect the way the service is delivered, this stifling innovation and creativity. Rather than appreciating the position of staff and the courage it took to blow the whistle the Acting Manager expressed disappointment in his staff team to the Inspector. The manager completes a monthly quality report and regulation 26 visits are carried out. Quality Assurance systems do not draw sufficiently upon outcomes from service users and others feedback. There was evidence of one relative providing the home with written feedback as requested by the home but no evidence that the response had been followed up and analysed as per the stated intention in the accompanying letter to the relative. This is of concern because although the feedback was largely positive there was potentially an area of concern that needs exploration. The comment states that that the service user can’t talk to anyone including the manager if there is a problem. This is particularly concerning given that the Acting Manager indicated that this service user is capable of having ‘a sensible conversation’. Third parties are not consulted for feedback. Staff were able to describe what they would do in the event of a fire. It is noted that Fire training for staff is up to date but due again July 2006. Fire drills had not been carried out since March 2006 and a risk assessment for one service user states he needs weekly fire drills. In house checks of the fire alarm system are being carried out weekly. Emergency Lighting service maintenance was out of date. The Fire officer last visited in September 2005 and changes were made as a result of advice given. Water valves have been fitted since the last inspection and temperatures are now being regularly monitored. Radiators are appropriately guarded reducing the risk of scolds to service users from water and surfaces. The COSHH cupboard was locked. Hazardous laundry chemicals were however found unattended in the laundry shed, this without a lock. Hazardous chemical data sheets are available but COSHH assessments have not been carried out to determine the level of risk or control measures that must be in place to protect service users from the risk of chemical injury. A first aid box is available but not in locations where notices indicate that they are stored. Prior to recent resignations most staff had a first aid qualification. Six remaining staff are first aid qualified. The falsification of the rota and failure to ensure that it accurately represents who covered shifts has made it impossible to judge whether each shift is staffed by someone qualified in first aid. Window restrictors are in place and all are restricted with the exception of one, which is not subject to assessed risk. In addition risk assessments are not in place for the general security of the premises. A legionella risk assessment has been commissioned since the last inspection. One area of high risk was identified by the contractor who recommended 3 monthly cleaning and chlorinating of shower head sprays. There was evidence that this has since been done once in February 2006 but not since. Chlorination of the system was last undertaken in October 2004 and samples Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 30 to measure the presence of legionella have not been taken and forwarded for analysis. The home is newly required to seek the advice of the Environmental Health Department given the number of outstanding requirements relating to Health and Safety. A previously required Lone working policy was not available on the premises when requested at inspection to appropriately guide staff and managers. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 1 3 1 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 1 12 2 13 1 14 1 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 2 X 1 1 1 X X 2 X Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 32 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 Registered Provider must update the Statement of Purpose. New Requirement June 2006 2 YA2 14 The Registered Provider must review the proposed new admission to Beaconhurst in full to ensure that the home can be satisfied that his needs can be fully met prior to admission. All assessments and care documentation must be in place prior to any admission. To confirm in writing to CSCI the review of this proposed admission and its outcome by 10 July 2006 with supporting evidence. Immediate Requirement at June 2006. The provider must ensure that accommodation is not provided to a service user at DS0000062601.V300260.R01.S.doc Timescale for action 30/09/06 10/07/06 3 YA2 14, 15, 13, 18 10/07/06 Beaconhurst Version 5.2 Page 33 the care home unless: The needs of the service user have been assessed by a suitably qualified or suitably trained person The registered person has a copy of the assessment The registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. A written plan is in place to show how the service users needs in respect of his health and welfare are to be met, based upon the assessment of need. All unnecessary risks to the health and safety of service users are identified and as far as possible eliminated with recorded evidence. It can be ensured that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. New Requirement at June 2006 The service users contract of 30/09/06 residence must be reviewed to include the stated fee, a 12 week trial period, and the service users right to use National Health facilities DS0000062601.V300260.R01.S.doc Version 5.2 Page 34 4. YA5 5(c) Beaconhurst without charge (Requirement made from Inspection June 17th 2005 and part met at June 2006) 5. YA6 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) 6. YA6 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. 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 part met at June 2006) 7 YA6 15, 12, 13 Care plans must include how 31/07/06 and when with what frequency service users assessed social needs are to be met. Sexuality guidelines must be in place in care plans. New Requirement at June Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 35 31/07/06 31/07/06 2006 8. YA7 12 Decision making must be 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. Requirement made at December 2005. 9. YA16 15, 12 Care plans must include service users preferences re mail management Requirement at December 2005. 10. YA17 13(4)(c), 15) 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. 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 June 06) 11. YA17 16(2)(i) Sch 3(3)(m) Quantity of food eaten must be recorded in the food intake records. (Requirement made from Inspection June 17th Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 36 31/07/06 31/07/06 31/07/06 31/07/06 2005.) 12 YA17 16(2)(i) The provider must review systems in place to ensure that there is sufficient money available to the home at all times for the on going provision of food in adequate quantities. This must not include a dependency on staff to fund food from their personal monies. Action taken must be confirmed in writing to CSCI BY 31/07/06 New Requirement June 2006. All aspects of personal care must be included as guidance in plans of care and must be based upon assessed need. Requirement made at December 2005. 14 YA20 13(2) The recommendations of the supplying Pharmacist at support visits including those from May 2006 must be complied with. E.g. 1. Add second signature for handwritten records of creams (this not done). 2. To document the site of application of creams – not documented on Mars records. Service users or where appropriate their representative’s consent to the administration of medications must be obtained and retained on file. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 37 26/06/06 13. YA18 15 31/07/06 30/06/06 15. YA23 13(6) New Requirements at June 2006 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. Requirement made at December 2005. 31/07/06 16. YA23 13(6) 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. Requirement made at December 2005 31/07/06 17. YA23 13(6) Action (e.g. retraining / supervision/ mentoring etc must be taken where it is identified that there are gaps in staff knowledge re the DS0000062601.V300260.R01.S.doc 31/07/06 Beaconhurst Version 5.2 Page 38 causes of behaviour that challenges. Staff performance re behaviour management / support must be monitored closely. Requirement made at December 2005 18. YA23 13(6) 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. Requirement made at December 2005 19 YA23 13(6) There must be two signatures on transactions on records of monies in safekeeping. The service user, who has previously signed for his financial transactions within the home must be enabled to resume this unless there are clear, recorded reasons for not doing so. New Requirement at June 2006. 20. YA30 23(5)13(3) A risk assessment to minimise the risk of cross infection must be developed and adhered to. (Requirement made from Inspection June 17th 2005) 21. YA33 18(1)(a) Written confirmation of contingency arrangements to cover arising vacant shifts must be provided to the DS0000062601.V300260.R01.S.doc 31/07/06 31/07/06 31/07/06 30/06/06 Beaconhurst Version 5.2 Page 39 Commission for Social Care Inspection. (Requirement made from Inspection June 17th 2005) 22. YA33 18(1)(a) Staffing ratios must be maintained at all times. (Requirement made from Inspection June 17th 2005) 23 YA33 18, 17(2) Sch 4 (7) Staffing levels must be reviewed based upon the assessed need and dependencies of services users. Appropriate staffing levels must be provided at all times including at night. The home must be effectively managed at all times, through the provision of sufficiently experienced and qualified senior staff. Rotas must be accurate and accurately represent staffing availability and shifts worked. Written confirmation must be sent to CSCI detailing action taken to meet the above by 28.6.06 Immediate Requirement at June 2006. The practice of staff under the age of 21 taking responsibility for a care home must cease immediately. Written confirmation must be sent to CSCI by 28.6.06 detailing action taken. New Immediate Requirement at June 2006 Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 40 26/06/06 28/06/06 24 YA33 13 (2), 18 28/06/06 25. YA34 19 Staff files for all staff employed must be retained on the premises and must be available for inspection. Requirement made at December 2005 31/07/06 26 YA34 19 The registered person must 30/06/06 review and improve practice in relation to obtaining and authenticating sufficient written references and identification prior to employment of staff in accordance with regulation. New Requirement at June 2006. All staff including senior staff and Managers must be provided with an individual copy of the General Sopcial Care Councils Code of Conduct. New Requirement June 2006. 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 and not met at December 2005 - 3 staff done Makaton) At June 06 3 staff still employed undertook autism training in April 06 The provider must confirm in writing to the Commission for Social care Inspection an action plan to ensure that DS0000062601.V300260.R01.S.doc 27 YA34 18(4) 31/08/06 28. YA35 18(1)(c)(i) 30/09/06 29. YA35 18(1)(c) 31/07/06 Beaconhurst Version 5.2 Page 41 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 or June 06) 30. YA35 13(6), 18 All staff must be provided with 30/09/06 adult abuse / protection training which must be booked by the date given. New Requirement at December 2005 3 staff received in Feb 06. Required for new staff 31 YA35 13(6) 18 30/06/06 The registered person must ensure that where alternative training in physical intervention is commissioned that it is accredited, consistent with the principles in DOH guidelines and complies with earlier training provided to some staff to ensure a whole team consistent and safe approach to the management of behaviours that challenge. Outcomes must be confirmed in writing to CSCI. New Requirement June 2006. The Provider is required to inform CSCI by Friday 30 June what action is proposed to ensure that the home is appropriately managed (following concerns identified at this inspection) and staff appropriately guided. 32 YA37 7, 8, 9, 19, 13(6) 21(2) 30/06/06 Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 42 CSCI must be informed in writing by Friday 30 June as to how it is proposed to support staff who have raised their concerns. The Registered Person must investigate the allegation that the Company vehicle was used for personal use from 7 – 10th June 2006, take action appropriately depending upon the outcome and report the outcome in writing to both CSCI and Social Services (Reports must be received by Friday 30 June 2006.) The Registered Person must provide to CSCI further authenticated evidence appertaining to the reason for a service users holiday cancellation. This must be received by CSCI by Friday 30 June 2006. New Requirement at June 2006 The provider is required to investigate the approach of the Acting Manager as evidenced during this inspection, taking action where required with outcomes confirmed to CSCI in writing. 33 YA37 8, 9, 19 31/07/06 34 YA37 37, 17(2) New Requirement at June 2006 The registered person shall ensure 30/06/06 that CSCI is notified of all incidents as defined by Regulation 37 including staff dismissals. The provider must ensure that CSCI is notified on each occasion that assessed staffing levels are not met; this includes night shifts and the presence of senior staff on each shift. 35 YA37 9 New Requirement at June 2006. The provider must ensure that an DS0000062601.V300260.R01.S.doc 31/08/06 Page 43 Beaconhurst Version 5.2 application for the registration of a manager is submitted to CSCI for consideration by the date given to improve the homes management and overall performance. 36. YA39 24 New Requirement June 2006. The registered person shall 30/09/06 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 consultation with service users and their representatives. Outcomes of quality assurance reviews must be made available to service users and the Commission for Social care Inspection. Requirement made at December 2005 37 YA39 24 The provider must investigate to clarify the outcome of carer feedback provided in a completed questionnaire, which stated that, the service user can’t talk to anyone including the manager if there is a problem. The outcome of investigation must be provided in writing to CSCI with action taken if appropriate to improve the service. New Requirement at June 2006. A Policy on Lone Working must be developed / available and a copy supplied to the Commission for Social care Inspection. DS0000062601.V300260.R01.S.doc 31/08/06 38. YA41 18(1)(a) 30/09/06 Beaconhurst Version 5.2 Page 44 (Requirement made from Inspection June 17th 2005) 39 YA41 17 Records required by regulation 30/06/06 for the protection of service users and for the efficient running of the business must be maintained in good order, must be up to date and must be accurate. Records required by regulation must be available for inspection and must be presented to CSCI upon request. New Requirement at June 2006. The provider must ensure that a copy of the duty roster of persons working at the care home is accurately maintained. This must include a record / signed statement to indicate whether the roster was actually worked A copy of the staff roster must be provided each month in arrears to CSCI until further notice. New Requirements June 2006. The use of the wall mounted gas 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 Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 45 40 YA41 17(2) (7) 37 30/07/06 41. YA42 13(4)23(5) 31/07/06 Inspection June 17th 2005) 42. 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) 43. YA42 13(4) All COSHH products must be appropriately stored. (Requirement made from Inspection June 17th 2005) 44 YA42 13(4) COSHH assessments must be developed using data sheets obtained for all chemicals stored and used within the home. New Requirement June 2006. To implement the homes own risk assessment in place for one service user, which states weekly fire drills are required. New Requirement at June 2006. To ensure that emergency lighting systems are serviced with sufficient regularity and evidence retained New Requirement June 2006. First Aid boxes must be kept in all identified designated locations within the premises. To review numbers of current staff qualified in first aid Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 46 31/07/06 26/06/06 31/08/06 45 YA42 13(4) 23 30/06/06 46 YA42 23 31/07/06 47 YA42 13(4) 31/07/06 ensuring each shift is staffed by an appropriately qualified staff member. Confirm outcome of review to CSCI New Requirement June 2006. To ensure that showerheads are cleaned and chlorinated 3 monthly with records kept as per outcome of commissioned water risk assessment. New Requirement June 2006. To seek advice from Environmental Health Department Health and Safety in respect of homes compliance with Health and Safety Legislation New Requirement June 2006. 48 YA42 13(4) 31/07/06 49 YA42 31(4) 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA23 YA31 Good Practice Recommendations The provider should consider reimbursing service the service user’s £16.80 library fine. There should be evidence on each staff personnel file of the issue and receipt of appropriate job descriptions. Beaconhurst DS0000062601.V300260.R01.S.doc Version 5.2 Page 47 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.V300260.R01.S.doc Version 5.2 Page 48 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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