Inspection on 28/06/07 for Beaconsfield Care Home

This inspection was carried out on 28th June 2007.

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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaconsfield Care Home 29/07/08

Beaconsfield Care Home 28/01/08

Beaconsfield Care Home 14/09/06

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Beaconsfield Care Home 13 Nelson Road Southsea Portsmouth Hampshire PO5 2AS Lead Inspector Annie Kentfield Unannounced Inspection 28th June 2007 10:00 Beaconsfield Care Home DS0000066435.V338741.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 Beaconsfield Care Home DS0000066435.V338741.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. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaconsfield Care Home Address 13 Nelson Road Southsea Portsmouth Hampshire PO5 2AS 02392824094 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) triniraj@sky.com Beaconsfield Care Limited Mr Rajendra Mahadeo Care Home 21 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (21) of places Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users admitted within the LD category must also have a mental health diagnosis. 14th September 2006 Date of last inspection Brief Description of the Service: The current owners of the home have been registered since February 2006. At the time, the Commission was in the process of taking enforcement action against the previous owner because the home was considered to be a failing service, however, the previous owner then decided to sell the home. The building was in a poor state of repair and the new owners have undertaken considerable building and roofing work to make the home safe and weatherproof. One of the registered owners is also the registered manager of the home. The premises is an end of terrace, period property that has three floors, a converted basement and an extension giving it 21 registered places for residents within the categories of Learning Disability (LD) and Mental Disorder (DE). There is parking on the street and public transport in the area is good. The home is situated only a short walk from the main shopping area of Southsea, in addition a number of local convenience stores are accessible to the residents and their visitors. Access to all of the floors is via stairs and the home is suitable for residents who are fully mobile. The current scale of charges is from £332.57 to £374.85 per week – this includes the cost of care, food and laundry. Residents pay for their own toiletries, chiropody, hairdressing etc. Some of the residents have travel tokens or bus passes. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report provides a summary of information received about Beaconsfield since the last inspection of 14 September 2006. Before the unannounced inspection visit of 28 June 2007 the residents were sent comment cards to complete if they wanted to – 9 were returned and indicated that residents are satisfied with the care provided by the home. Registered care services now have to complete an Annual Quality Assurance Assessment and evidence from this is also included in the report. Comment cards were sent to Care Managers, Mental Health Practitioners and a GP Surgery and one has been returned. Two inspectors carried out the unannounced visit to the home - one was a pharmacist inspector. This was because the information supplied by the registered manager in the Annual Quality Assurance Assessment (AQAA) identified a possible concern with drugs and medication; also the previous inspection report had identified some issues of concern with the home’s medication storage and procedures for dispensing medication. The outcome of the pharmacist inspector’s assessment is included in the section ‘Personal and Healthcare support’ and there are some statutory requirements that the home must comply with in the given timescales with regard to medication. The second inspector looked at other aspects of the care provided by the home and this included discussion with some of the residents in the communal areas of the home, discussion with care staff, the registered manager, the administrator, and inspection of some of the home’s records. The inspection visit covered one day from 10am to 6.30pm. Statutory requirements made at the previous inspection have not been addressed: the home has not reviewed and updated their risk assessments, or produced a training plan for staff that meets the specific needs of the residents in the home. There were also Good Practice Recommendations that have not been carried out. Failure to comply with statutory requirements has the potential to put the welfare and safety of the residents at risk. The registered providers must comply with statutory requirements within the given timescales. What the service does well: Comments from residents and observation of life in the home indicate that the lifestyle of the home suits the needs and preferences of the residents: “I enjoy my stay here and I am happy” “I’ve been here for 13 years, I’ve got no complaints, if I did have I wouldn’t be here now”. It was also evident from observation and discussion with residents that care staff know the residents well and care and support is provided that respects individual needs and preferences. A Mental Health Practitioner wrote, “The Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 6 home is good at allowing service users to live as independently as possible whilst promoting choice and balancing risk”. Comments from residents also indicated that the food has improved in quality since the home has been under new ownership. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The system for assessing the needs of prospective residents needs to be reviewed (this was a recommendation from the previous inspection) to demonstrate that the home is considering all of the individual needs of residents and how they will be met – before the resident moves in. The home needs to develop ways of producing information about the home that is easily understood by the residents. The home has not addressed a previous requirement to ensure that trained and qualified care staff can meet the residents’ specialist care needs. EVIDENCE: The Service User Guide should contain all of the information that a new resident needs to make a decision about moving into a care home, and what they can expect from the service. Unfortunately this information was not available during the inspection visit and the new resident that the inspector spoke to was not sure if they had received it or not. Although the home has identified that they need to improve how they provide information, such as producing information in other formats, (not just written), this is an area that still needs to be developed. Records and discussion demonstrated that the care needs of new residents are assessed before they move into the home, to ensure that the home is able to Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 9 meet those care needs. Information is requested from health and social care professionals who are involved in prospective residents’ care. The last inspection recommended that the home review their assessment process to ensure that they spend time and effort making admission to the home personal and well managed, responding to individual needs for information, reassurance and support. Although it was evident that the home has identified this as an area to be improved and have stated that they plan to review the process – this is an area that still needs to be developed. Discussion with care staff indicated a level of knowledge and awareness about the care needs of individual residents and how mental health problems can affect the lives of the residents. However, the lack of good quality training for staff means that staff may not be aware of current good practice in meeting the specialist needs of the residents and there is the risk that some care needs may not be identified or met. The last inspection required the home to produce a plan of how staff training and development will meet the needs of residents with mental health problems or a learning disability, but this has not been complied with in the given timescale. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home recognises the right of the residents to make their own decisions and choices but the practice of involving residents in the development and review of their individual care plan is variable. The individual care plans do not consistently reflect the care being delivered. EVIDENCE: Comments from residents in the comment cards confirmed that they do make daily decisions about what they do and where they go, also that staff support them in this. All of the residents (except one new resident) has an individual plan of care and generally, these contain the information necessary to supporting and providing care to each resident. Each care plan has a good ‘pen picture’ and photo of the resident and they are easy to read. The practice of involving the residents in their own care plans and care plan reviews could be improved and this would demonstrate that the service is fully committed to supporting residents to make their own informed decisions and focus on each residents’ strengths and personal preferences. The home needs to develop Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 11 good practice in ‘Person Centred Care Planning’ so that care plans are developed with and owned by, the individual resident. This is where the previous recommendation to develop the care assessment process is relevant because a full and comprehensive care assessment should provide the necessary information for the individual care plan. Regular reviews of the care plan should identify changing needs and personal goals and the care plan should reflect this. Risk assessments are completed but these are basic and mainly focus on documenting where there are limitations in place. Risk assessments must be developed to include an agreed plan for management of risk where the need is identified and also cover all daily living activities. This was also identified at the previous inspection and a statutory requirement was made but has not been addressed within the given timescale for action. Residents in the home are involved in lots of activities that they like doing and the home must ensure that appropriate risk assessments are carried out and a plan agreed on managing any identified risk to ensure the residents’ safety and well being at all times. This was discussed in some detail in the last inspection report but it was evident in discussion that staff in the home had not been shown the previous inspection report and were therefore unaware of where improvements in practice must be made. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff are aware of the need to support residents to develop their skills, interests and hobbies, and independent living skills. Some residents are consulted or listened to regarding the choice of daily activity, but this process could be improved. EVIDENCE: Observation of the lifestyle in the home showed that the daily routines are informal and staff are aware of residents’ choices and preferences for going out or staying in the home. Some of the residents go to the cinema, shopping, the library, church and other outings of choice. One resident is doing a college course and another resident is awaiting a day centre place. The senior carer explained that she tries to be flexible with the staffing arrangements so that a member of staff is available to go out with a resident when support is needed. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 13 Some of the care staff have, on their own initiative, set up opportunities for residents to take part in creative art and craft sessions, games etc. and this positive approach should be included in the individual assessment and person centred care planning for each resident. Some of the residents take the opportunity to discuss the daily activities of the home in the residents meetings. The last one was on 31 May. However, although it is recorded that residents identified a number of activities they would like to do, no member of staff has been delegated to ensure that these activities are offered. Although there are facilities in the home for residents to make drinks or snacks there is no framework in place for assessing and developing residents’ daily living skills and the residents’ ability to make use of these facilities is not monitored. Not all of the residents are consulted on how the home can work to provide them with a flexible lifestyle or offer the activities they would like. This is because not all of the residents want to go to the residents’ meetings and are less likely to socialise in the home because of their disability or particular communication needs. The home recognises this and plans to make some changes. This has been identified by the home in the Annual Quality Assurance Assessment – under ‘What we could do better’ the registered manager has stated that the home would like to “support residents to develop their emotional and independent living skills. The home needs to develop this area of their service so that all residents are individually assessed and their goals, choices and preferences are recorded in their care plan. Regular reviews of the care plan with the resident would identify goals met and any changes. This would ensure that residents are fully involved in the planning of their lifestyle and quality of life. In order to develop a person centred care planning approach in the home, the registered manager would need to provide staff with the training and knowledge of person centred care planning so that staff feel confident and supported in their work with the residents. When considering how the service can support the residents to develop independent living skills, it would be good practice to look at how residents could be supported to manage their own finances. With the exception of only 3 residents – the personal monies of all of the residents are paid into a corporate account for the home and allowances are allocated on a daily basis. This does not encourage or support independence for the residents. In addition, the residents do not receive any interest that may accrue as they would if they have their own personal bank account. The Commission website www.csci.org.uk contains a range of guidance for care homes including good practice in the management of service user finances. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lack of policies, procedures, guidance and training available to care staff to demonstrate that the home can promote good health care for residents. However, there is evidence that residents have access to health care services. There are some gaps in information and improvement is needed to the way that health care is recorded and health care needs monitored in the care plans. Improvement must be made to the home’s policy and procedures for the safe administration of medication. EVIDENCE: The safe handling of medication was assessed by a pharmacist inspector. The medication records, procedures, the storage were looked at and the inspector watched staff giving medicines to residents. Some people chose to keep and use their medicines themselves. These people were supported to do this in a way that kept them and other people in the home safe. Most people had their medication given to them by the care staff. These staff had been trained and had been deemed competent to handle medicines by a senior carer in the home. The provider was not able to show Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 15 that the person providing the training had up to date knowledge in the subject of medicines and so the quality of this training could not be verified. This could mean that staff do not have up to date knowledge, which may result in people not receiving adequate care. Medication procedures were available for the staff to refer to. They however did not cover all aspects of safe medication handling and described a practice no longer considered safe. This was when staff were instructed in the procedures to add any newly prescribed medicines to the chemist filled Nomad trays. Staff should give medicines from the original labelled container they receive from the pharmacy so as to reduce the chances of making a mistake. Medication was stored securely for the protection of the people who live in the home. However staff who were not trained to handle medicines could access them as keys to other secure parts of the building were kept with the medicine keys. This means that staff not authorised to have access to medicines are being given the keys to the medicines store. Controlled drugs were stored securely, though the cupboard did not meet the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973. Records were kept when staff gave medicines to people who live in the home, including when medicines were not given with the reason why. There were a small number of gaps in these records. It was possible to tell during the inspection that people had received their medicines on these occasions as the doses had gone from the medication trays that the pharmacy supply to the home. However if the trays had been returned to the pharmacy and only the written records remained in the home it would not have been possible to tell if people in the home were receiving the medicines prescribed for them. Also the dates on the record charts did not match the days of the week listed and so there could be a doubt as to which was correct if the records had to be relied on at a later time to see what treatment someone received. Records were kept of medicines received into the home but not of any medicines leaving the home. This means it would not be possible to tell if any medicines were lost. Additional records were kept of the use of any Controlled Drugs, which would identify any loss of these medicines. Health and Personal Care Residents have access to GP services, optician, chiropodist and other specialist services and can access these either in the home or in the community. Some information about the health care needs of the residents is included in the care plans and staff demonstrated an awareness of individual needs and preferences for the way that personal care and support is provided. This is evident from the positive relationships between staff and residents. Care staff were able to give a verbal update on how the health care needs of the residents are monitored and appropriate action and intervention taken. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 16 However, this information is not always recorded in the care plan and there is the risk that some health care needs may be overlooked. Better systems for recording and reviewing health care needs would ensure that every resident has their health and personal care needs clearly set out, regularly reviewed with a proactive and ongoing monitoring of their physical, psychological and emotional care needs. This would also ensure that residents are offered access to health promotion services that they may miss out on such as access to help with giving up smoking, contraception, sexual health, or advice and information about general health care issues. The home does not have a plan for staff training and development, therefore, care staff may not have up to date knowledge about the care of residents who have complex physical and mental health care needs and changing care needs related to getting older. Some of the residents may not be able to verbally communicate their care needs and unless care staff are given specific training and knowledge in communication skills, there is a risk that the specific health care needs of some of the residents may be overlooked, putting them at risk. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The systems for seeking the views of the residents need to be more consistent to demonstrate that residents’ views are listened to and affect the way the home is run. The arrangements for protecting residents are not satisfactory placing them at possible risk of harm or abuse. EVIDENCE: Comments from the 9 residents who returned comment cards indicated that they would speak to a member of staff if they had any concerns or complaints. The report has identified that the home needs to develop the ways that residents are offered information about the home, including the complaints procedure. This would ensure that residents are offered information in a format that is easily understood. The home needs to develop a quality assurance process that offers all of the residents the opportunity to have their views about life in the home listened to, with evidence that residents’ views, concerns and compliments are acknowledged and acted upon. This happens some of the time in the residents’ meetings and when residents are asked what food they would like. The home needs to develop a process of ensuring that this happens all of the time so that residents are confident that their views are valued and respected. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 18 The practice in the home does not routinely monitor staff awareness of the policies and procedures in place for safeguarding adults. The last inspection of the home recommended as good practice that there should be a review of staff training to include updates for staff on Safeguarding Adults policy and procedures. The home has failed to carry out this recommendation and cannot safely demonstrate that staff are aware of their responsibility to protect the residents. Since the last inspection the standard of vetting and recruitment practice has declined with appropriate checks not being carried out and potentially leaving residents at risk of harm. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvements to the fabric of the building but the bathrooms used by the residents are in urgent need of repair and refurbishment. Generally the home is clean and tidy but the home must seek advice to ensure that there is a policy, procedures, and equipment in place to promote good hygiene and the control of infection. EVIDENCE: The registered owners have had to undertake considerable work on the building and since February 2006 a lot of work has been put into repairing the roof, painting the exterior and generally ensuring that the fabric of the building is sound. The poor state of the roof caused a ceiling to come down in one of the upstairs bedrooms and the resident is temporarily in another bedroom. Most of the bedrooms are single but there are four shared bedrooms Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 20 Work has started on a project to provide accommodation for the owners in the attic rooms. However, the owners must also address the poor state of the bathrooms used by the residents. One bathroom is still without a ceiling and was identified as a concern at the inspection of September 2006. There is a bathroom and toilet on each floor of the home and all are in need of replacement. The poor state of the toilet cisterns mean that toilets regularly overflow and flood the floor. The inspector observed staff having to deal with this during the inspection visit. Some decoration has been carried out internally and the living room has been decorated. Areas of the home are still in need of decoration, refurbishment and replacement of carpet. The registered owners need to demonstrate that they have a long-term plan with reasonable timescales for the refurbishment of the building that prioritises those areas that most affect the residents’ safety and comfort. Since the last inspection the home has appointed a cleaner who works 12 hours per week. Comments from residents and staff demonstrate that the home is looking cleaner and tidier. The home does not have a policy and procedures for staff that promotes good hygiene and the control of infection. There is a lack of suitable facilities and equipment provided for staff, for example there is no liquid soap or paper towels provided in the laundry or in any of the toilets and bathrooms. This means that staff are not able to wash their hands after doing any cleaning or laundry tasks. Staff do not have their own bathroom and use the same one as the residents. The home must seek advice from an infection control specialist and undertake a risk assessment of practice in the home. This will ensure that practice in the home does not put the health and welfare of the residents and staff at risk. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home needs to develop a good quality training programme and improve their standards of recruitment vetting to ensure that residents are safe and protected. EVIDENCE: We spoke to staff in the home and looked at one recruitment file. Having a trained and confident staff team will help the home to better understand the needs of the residents and meet their needs in a professional, safe, and competent way. Work is still needed to develop this. The records of training were not available for inspection. This means that the inspector was not able to confirm the information provided by the registered manager in the Annual Quality Assurance Assessment that states the home now has a staff training and development plan with an allocated budget. Staff said they had recently done some training in safe moving and handling. Some of the staff have done relevant training in their previous employment but would like to update this. The home needs to have a comprehensive training plan and maintain records of training that has been undertaken so that regular Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 22 updates of training are arranged. The home must ensure that staff have received training in all areas of safe working practice and provide regular supervision and monitoring to ensure that staff are following safe practice at all times. Since the last inspection the home has taken on new staff. The Care Homes Regulations 2001 require homes to have a thorough recruitment procedure and undertake checks to make sure that residents are safe. Since the last inspection the standard of vetting in the recruitment procedures has declined and some essential checks are not being carried out. This has the potential to put residents at risk. New staff follow an induction with one of the senior carers. The home has a basic induction programme that covers the important information that new staff need to know such as fire safety, confidentiality, writing daily records etc and this covers their first few days of working in the home. A more comprehensive and structured induction for new staff would provide staff with training on the principles of care, safe working practices, and the particular requirements of the residents in the home. This would provide a basis for further training in those specialist areas relevant to the needs of the residents. Because the home has no records of a comprehensive induction training programme for new staff or regular staff supervision, there is no evidence that staff have the opportunity to discuss good practice in their work with the residents, or discuss their training and development needs. The lack of supervision records also means that no-one is regularly monitoring the way that staff work to ensure that working practice in the home is safe for residents and staff at all times. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home would benefit from clarity of management roles and duties and for the registered manager to have a recognised management qualification. The home does not have a system of quality assurance that monitors how well the service is meeting the needs of the residents. EVIDENCE: When the registered manager is not in the home – the day-to-day responsibility for the home is with the two senior carers. This system seems to work well for the residents who clearly have a good relationship with all of the staff in the home, including the registered manager. However, because a lot of the records that need to be inspected by the Commission, could not be found when the registered manager is not there – the home was not able to demonstrate that there are clear lines of responsibility and accountability within the home. Staff were able to confirm that some of the required health Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 24 and safety checks were being done, but staff, for example, were not aware of the home’s fire safety risk assessment or where a copy would be kept. This means that the home is not able to demonstrate that they are meeting all of their required duties to undertake regular checks and keep records of their health and safety responsibilities. This means that the safety and well being of the residents and staff could be at risk because there are no clear lines of responsibility within the home for who should be checking on all aspects of health and safety and safe working practice in the home. It is also clear that the level of delegated responsibility to senior staff is minimal. Registered managers of care homes need to demonstrate that they have a formal management qualification and although an undertaking to achieve this was given to the Commission when the manager was registered in 2006, this has not been addressed. The registered manager has considerable and relevant experience in the area of mental health. However, the lack of efficient and organised management systems in the home means that the home may not be operating in a way that is safe for the residents and staff. Good record keeping would be one way of demonstrating that the home is safely managed but not all of the records are available, up to date, or in good order. The home has a duty to notify the Commission under Regulation 37 of the Care Homes Regulations 2001, if there is any incident that affects the safety and well being of the residents. Records show that there have been a number of incidents (including the incident where a ceiling fell down in a residents’ bedroom) that have not been reported to the Commission. Failure to do this could affect the safety and well being of the residents in the home. The home does not have a system for quality assurance that measures how well the service meets the needs of the residents. The quality assurance or quality audit should seek regular feedback from the residents, staff, and visitors and be part of the home’s development plan. The quality audit should also provide evidence that there are good systems of organisation and management in place that promote the residents and staff safety and wellbeing. The quality audit should also regularly measure how well the service is meeting the National Minimum Care Standards and ensure that the service is compliant with the Care Homes Regulations 2001. The registered manager has identified in the Annual Quality Assurance Assessment that the home needs to develop a good quality assurance system but this has not yet been addressed. Discussion with staff during the inspection visit indicated that the previous inspection report; the recommendations for good practice, and the statutory requirements, had not been discussed with staff. Requirements and recommendations are made where practice in the home must improve to ensure the safety and well being of the residents. The registered manager also has a legal obligation to ensure that statutory requirements are met, within the timescales given. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 25 Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 26 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 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 1 33 X 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 2 X 2 X X 2 2 Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 27 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 YA9 Regulation Requirement Timescale for action 16/08/07 Regulation The home’s risk assessment 13 documentation requires reviewing and updating to ensure any risks to the residents are easily identifiable and plans to manage these risks are clear and concise. This will ensure that residents’ safety is considered at all times. This is a repeat requirement and the previous timescale of 11/11/06 has not been met. 2. YA20 3. YA23 Regulation The policies, procedures and 30/07/07 13(2) practice relating to the handling, storage, recording and safe administration of medication must be reviewed and updated in line with the guidance from the Royal Pharmaceutical Society document ‘The Administration and Control of Medicines in Care Homes and Children’s Services’, 2003. Regulation So as to protect the people who 16/08/07 13(6) use this service from harm or abuse, the registered manager must ensure that all staff are aware of their responsibilities to DS0000066435.V338741.R01.S.doc Version 5.2 Page 28 Beaconsfield Care Home 4. YA24 Regulation 23(1) 5. YA32 YA35 Regulation 18(1) 6. YA34 Regulation 19 and Schedule 2 7. YA39 Regulation 24 8. YA42 Regulation 23(4) 9. YA42 Regulation 37 safeguard the residents; through knowledge of the home’s policies and procedures/ staff training and development and interagency safeguarding adults policy. All bathrooms and toilets used by the residents must be brought into a state fit for use, and ceilings replaced. Fittings must be working and suitable for the needs of the residents. So as to protect the welfare of the people who use this service, staff must be trained and deemed competent in fire safety, health and safety, food hygiene, infection control, safe moving and handling, first aid, and dealing with challenging behaviour. So as to protect the residents in the home, the recruitment checks for new staff must provide a satisfactory Criminal Record/POVA check, two satisfactory written references (one must be from the last employer) and a full employment history, before staff start working in the home. So that the home can measure how well the service is meeting the needs of the residents – there must be an effective system of quality assurance that reviews the quality of the service at regular intervals. So as to protect the residents and staff the registered manager must consult with the fire safety officer with regard to a fire safety risk assessment that meets current legislation. So as to protect the residents, any incidents affecting the safety, welfare or well-being of the residents must be notified to DS0000066435.V338741.R01.S.doc 16/10/07 16/10/07 20/07/07 16/10/07 30/07/07 20/07/07 Beaconsfield Care Home Version 5.2 Page 29 the Commission for Social Care Inspection without delay. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that a Controlled Drugs cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973, is provided for the secure storage of any Controlled Drugs, including Temazepam, which are prescribed for people who use this service. Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beaconsfield Care Home DS0000066435.V338741.R01.S.doc Version 5.2 Page 31 - 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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