Inspection on 05/01/06 for Beauly Way

This inspection was carried out on 5th January 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beauly Way 23/10/07

Beauly Way 28/06/06

Beauly Way 17/06/05

Beauly Way 11/01/05

Beauly Way 28/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Beauly Way 4 Beauly Way Rise Park Romford RM1 4XD Lead Inspector Catherine McGeoch Unannounced Inspection 05 January 06 09:20 Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 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 Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 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. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beauly Way Address 4 Beauly Way Rise Park Romford RM1 4XD 01708 756624 01708 372293 yinka@outlookcare.org.uk 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) Outlook Care Olayinka Odelola Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17th June 2005 Brief Description of the Service: Beauly Way is a purpose built home for 6 younger adults (all males) with learning disabilities and offers 24 hour care. Accommodation is on two floors and all bedrooms are single occupancy. There is a secure garden for service users to use. The home is situated in a residential area of Rise Park and is near to local shops. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, which meant that the home did not know that the inspector was coming. The inspection started at 9.20am and finished at 5.30pm. The inspector looked at two service users files, spent time with service users, observed staff, spoke to some staff members and completed an inspection of the premises indoors and outdoors. In addition, a medication audit was undertaken which included checking the medication administration sheets against the prescribed medication. There is ongoing concern regarding the recording of medication, resulting in further requirements being made and a referral being made to the Commission for Social Care Inspection’s Pharmacy Inspector. There has been a significant change in the staff team and it would appear that this has adversely impacted on the service. At the time of the inspection, the atmosphere within the home appeared calm and welcoming and the service users interacted appropriately with one another as well as staff members. A number of requirements made at the last inspection have not yet been met and have been restated in this report with a new timescale for compliance. Unmet requirements impact on the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. All core standards were covered during the two inspections carried out in the home during the last 12 months. What the service does well: What has improved since the last inspection? Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 6 Since the last inspection the registered manager has had 2 service users bedrooms decorated to a good standard. It was a requirement during the last inspection that one of the bedrooms be redecorated. The living room and hall carpets have now been cleaned and the premises were free from any odours. In addition, the drop leaf table on landing has now been moved and therefore no longer blocks the access to the fire extinguishers. 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. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 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 Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were met last time so were not covered at this inspection. EVIDENCE: Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 9 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): 6,9 The assessed and changing needs of service users are not routinely recorded in their individual person centred plans and some of the actions within the risk assessment are not taking place. As a result service users health, social and support needs are not being fully met which places them at risk. EVIDENCE: Service users’ continue to have individual person centred plans, which should cover all of their personal, health and social support needs. However, rather than reviewing and updating these plans, the home has now introduced another system for monitoring the goals and skills of individuals. The new system highlighted some realistic aims and objectives, but did not include that some service users participate in helping with the household chores under supervision. Moreover, it did not fully incorporate the changing needs of service users and how these would be met. At the time of the inspection the manager stated that these plans would be reviewed 6 monthly, but neither the person centred plans or the skills and goals plan recorded how and when the review would take place but there were minutes to support the review meetings take place. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 10 During the inspection of one file, it was apparent that the person centred plan was not being implemented/reviewed. The plan stated that the service user enjoyed a specific activity, however, this had never taken place. The manager stated that he felt that this service user would not benefit from this activity. However, as the service user had never been given the opportunity to participate in the activity, it is difficult for the home to justify how this decision was formed. Furthermore, the plan stated that the service user was attending a day centre, but had not done so for some months. When 6 monthly reviews take place or a service users needs change, this should be recorded on the person centred plan in order to evidence how the changing needs of individual service users are being met. Risk assessments were evident on the files inspected, and in one case was undertaken by an external health professional. The specific tasks identified to minimise risks in relation to the physical safety and health of this service user were not being undertaken within the home. This leaves this service user vulnerable and at risk. In addition, the Commission for Social Care Inspection had been notified of an accident regarding this service user on 06-12-2005, which could be attributed to the fact the actions from the risk assessment had not been implemented. This service user’s needs have changed significantly and the home have concluded that they are unable to meet their needs without an additional staff member. The manager stated that two meetings have taken place with the placing Local Authority regarding this, but funding was not agreed for additional staff. Instead, the service user should move to a more suitable resource. However, there has been a delay in this happening and as such their needs are not being met. There was no evidence of the minutes of these meetings and no clear timescales set for a new placement to be found. The home must ensure that once it is identified that a service user’s needs can no longer be met, that prompt action takes place to ensure the safety and well being of the service user and others living within the home. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15,16,17 The home offers service users the opportunities to participate in activities that take place within the community and provides assistance where necessary. However, there are two repeated requirements regarding the recording of meals and infringement of rights forms. EVIDENCE: Presently, there is one service user who attends a music group and the home arranges their own transport to and from the venue. This service user also attends church on a Sunday and is accompanied by a staff member. Another service user attends a day centre two days a week. Whilst inspecting the daily diaries it was evident that recently there was one occasion when the attendance at church did not take place “due to unforeseen circumstances”. The manager stated that some service users attended a Christmas party, which was arranged by MENCAP and on occasions they go out on local outings to the park, café and shopping. The manager stated that these outings were recorded in the daily diaries, however, appeared hesitant. Whilst inspecting the daily diaries the inspector noted some recent recordings of outings. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 12 These activities are a good way to ensure that service users are provided with the opportunity to socialise and participate in activities outside the home and with other people in the community. However, the home must ensure that the specific reasons why a service user has not attended a group or activity are recorded in order to ensure that service users are given the opportunity to attend their chosen activities. During the inspection, one service user was watching television and another service user was dancing to music, which they both appeared to enjoy. In addition, one service user has a musical instrument in their bedroom, which they said they like to play. During the summer, 4 service users went on holiday to Dover and each resided in their own caravan, 4 staff members accompanied them. The manager reports that this holiday went well, however, it was difficult to ascertain the views of the service users due to their verbal communication. The remaining two service users were taken on daily outings, which the home deemed more appropriate in meeting their specific needs. The manager reports that some service users have contact with their family and on occasions family members visit service users in the home, but in some cases service users also go out with family members. Contact with family members appears to be actively encouraged by the home. Currently two service users have keys to their own bedroom and retain the responsibility for locking their bedrooms. During the inspection service users were observed moving freely between the living area and the kitchen/dining area and doing what activity they chose. One service user is reluctant to go outside and the home must continue to ensure that a good level of opportunities are on offer and advice sought if necessary to ensure this service users needs are being met appropriately. One service user continues to have a baby monitor in his room to raise the alarm in the event that they suffer an epileptic seizure. A requirement during the last inspection was that an “infringement of rights” form be completed in respect of this device. The home has completed an “infringement of rights” form in respect of this matter. But, it was not signed or dated by the service user/advocate, family member or a staff member at the home. The manager signed and dated the form during the inspection and produced supplementary evidence that this matter had been discussed with the service user’s parent. Therefore, a repeated requirement has been made in respect of this matter. Once a week service users continue to enjoy a take away meal. A requirement was made during the last inspection that the content of these meals be recorded so that evidence is available to support that service users receive a balanced and nutritional meal. The manager stated that this is now happening Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 13 however, when the weekly menu was inspected the takeaway meal was not recorded, but was on an individual service users plan. The recording of the take away meal for this week was completed during this inspection, however is a repeated requirement. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The current practice within the home in relation to medication is putting service users at risk. EVIDENCE: There are currently no service users who are administering their own medication. During the inspection a medication audit was undertaken which included checking the medication administration records (MAR sheet) and one service user’s medication, which was held in the home. The home has now incorporated two systems for recording the medication, which made it very difficult for the inspector to carry out a full audit trail of medications coming in and out of the home. The medication administration records did not show how many medications are held in stock and the number of tablets brought forward every month. In addition, the system of recording according to the codes on the MAR sheets was not being implemented satisfactorily. For example, there were lines and other markings recorded on dates and times and it was not clear the purpose of such. Furthermore, it was apparent that the prescribed instructions for administering the medication was not being followed and mistakes were being made; there were some signatures in dates and times when a service user was Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 15 not due for the medication administration. The manager stated that he thought that this was an error in recording rather than the fact that the service user was administered the medication at inappropriate times. However, there was no written evidence of an explanation available on the MAR sheets, therefore, it is impossible to know the reason. The Commission for Social Care Inspection received two notifications in respect of two different service users not receiving prescribed medication. One on 0401-2006 where a service user did not received medication for two days and one on 05-01-2006 when a service user was not given medication that evening. The latter was on the day of the inspection when a high level of concern was raised regarding the safety of the recording and administration of medication. During a discussion with the manager, regarding who is trained in the administration of medication, he was unaware of what training the agency staff had been given outside the home. The homes policy states that staff that have not undergone external medication training should be observed by the manager or the deputy manager “if the manager thinks the deputy manager is competent” until deemed fit. In addition, there is a checklist assessment in place, which staff should complete before administering medication. The records of the observations that have taken place were unsatisfactory as they were sporadic and over a period of several weeks. In addition, the assessment checklist was limited in detail about how individual staff members had achieved the required level of understanding in order to reach the level of competence for administering medication. One staff member raised concern about an incident where a member of staff was on duty and was unable to administer medication therefore it was not given to the service user. As a result of the above, there is a high level of concern regarding medication and a referral has been made to the Commission for Social Care Inspections’ Pharmacy Inspector for a full medication audit. Two requirements were made regarding the recording of medication at the last inspection and requirements regarding medication were made at the inspection before that. Therefore, this is a repeated requirement and the registered persons must take urgent and robust action to address these shortfalls, otherwise the Commission for Social Care Inspection will take Enforcement action. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home has a clear adult protection procedure, which should offer service users protection from abuse and neglect. However, the staff team were not clear about what constituted neglect and did not consistently understand the policy/procedure for adult protection, which potentially puts service users at risk. EVIDENCE: During the inspection it was observed that staff understood different behaviours exhibited by individual service users and responded appropriately. The interaction between the staff on duty and service users’ was good and even though some service users have no or limited verbal communication staff appeared to understand their wishes and feelings. On occasions service users are physically restrained, which is either for their own or other people’s protection and this is carried out using the positive response method. The manager stated that all staff have been trained in this method of physical intervention and one staff member confirmed that they had received this training. When service users have been restrained the home has reported it to the Commission for Social Care Inspection. In one case, where there is difficulty managing a service users behaviour, the home has sought advice for behaviour management from the learning disability nurse, which is good practice. Discussions with staff members highlighted that some of their adult protection training was undertaken a few years ago and at the time of the inspection the manager was unaware of what training the agency staff had in relation to adult protection. In addition, one staff member was not aware of the home’s adult Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 17 protection policies and procedures. The issue around staff member’s knowledge and understanding of adult protection was taken up with the manager during this inspection and he produced a copy of the adult protection procedure which highlighted the necessary steps that should be taken in the event staff had any concerns regarding the safety and welfare of service users. However, the home must ensure that all staff members have a thorough understanding of adult protection and that they receive updated training on a regular basis. The service users finances were not seen on this occasion, but will be inspected fully during the next inspection. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 18 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): 26,28, The home was in a good state of repair and was clean and free from any offensive odours. Service users had some of their own belongings which made their bedroom look homely. EVIDENCE: Three service users bedrooms were observed during this inspection. Two service users bedrooms had been decorated since the last inspection to a good standard and all bedrooms appeared clean and well furnished. Some service users have televisions in their bedrooms and had some personal items such as photographs and pictures, this made it feel homely. One service user said that they liked their bedroom and that it was warm and comfortable. All service users apart from one, have the visual aid of a photograph of themselves outside their bedroom to help them identify their own room. On discussion with the manager there was no reason why the one remaining service user did not have his photograph outside his room and therefore one should be provided. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 19 All the rooms in the home were well ventilated and were welcoming. The carpet in the lounge and hall area had been deep cleaned and there were no offensive odours anywhere in the house. The manager said that there are plans to have new sofas and chairs in the living area. The garden and the rest of the grounds of the home were well maintained and there is now a summer house in the garden for service users to use. The summer house was donated by the family of a previous resident as a thank you to the home. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 20 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): 33,35,36 The home has undergone a significant change in staff since the last inspection and is largely reliant on agency staff and this appears to be adversely impacting on both service users and the remaining staff team. EVIDENCE: During the inspection there was 2 staff on duty with a third person working the middle of the day. The manager was present throughout the inspection and covered whilst staff were speaking to the inspector . The staff present appeared confident in their duties and conducted themselves in a professional and courteous manner. Since the last inspection there has been a significant staff turnover, and the majority of the staff team is made up with agency workers, although the manager informed me that 6 of the agency workers are regular to the home. Currently the home has 4 permanent care staff, which includes the deputy manager, the manager, a housekeeper and 8 temporary staff although the manager said that 6 of the temporary staff work in the home on a regular basis. The inspector was informed that another one of the permanent staff is due to leave shortly. There is a housekeeper employed part time that undertakes the majority of the homes domestic duties, although, recently has Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 21 undertaken some extra hours in caring for the service users in order to cover staff shortages. Through discussions with staff members there were concerns expressed by some about the level of staff turnover and the fact that this has impacted on service users. There was concern raised by one staff member about service users safety relating to some of the agency staff’s ability to administer medication appropriately. In addition, one staff member stated that they did not think service users needs were being met since the change in the staff team and provided the example that there were not enough people within the team to drive the car, which resulted in service users not being taken on outings. During this inspection three staff members were spoken and they all confirmed that they receive monthly supervision, yearly appraisals and that staff meetings take place once a month. Two of the three staff spoken to stated that they felt supported in their role, by the manager, and one said that the manager is “ready to listen.” However, one staff member was not happy with the level of support they were receiving. At the time of this inspection the manager did not know what training agency staff have received by their agency. This is very concerning and places service users at considerable risk. One staff member reported that they had undertaken training in First Aid, Epilepsy, health and safety, food hygiene and manual handling, however training records were not seen during this inspection. The manager stated that all the staff vacancies have now been filled and the home are waiting for the relevant checks to be completed before staff take up their posts. Whilst this is very positive, that once again the service users and home will benefit from a consistent staff team, there will be a further period of inconsistency whilst the new staff complete their induction programme and are competent in meeting service users needs. The manager stated that due to the fact the home is short staffed and the increasing needs of one service user, he is now providing cover in caring for service users on a regular basis. This is having an impact on the running of the home. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,42 Given the content of this report, which includes unmet requirements from the last inspection, this reflects poorly on the conduct and management within the home. EVIDENCE: Due to the service users level of communication it is difficult for the home to ascertain their views through verbal communication. However, there was evidence on one service user’s file that family members are invited to participate in the planning and reviewing of service users needs and their views recorded within the minutes. All of the service users are in receipt of an advocacy service provided by MENCAP. On occasions the advocacy officer is invited to service user reviews to ensure an independent view on behalf of the service user is obtained which is good practice. However, advocates/family members had not signed paperwork relating to the infringement of rights (as mentioned previously). Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 23 The home appears to work well within the multidisciplinary team involved with some service users and there was evidence that advice and support had been sought from different professionals outside the home. Service users meetings are held quarterly where they have the opportunity to participate in discussions about the home. Whilst this is a positive approach the inspector is unsure about how service users are able to contribute and therefore, benefit due to the level of their current communication. Service users records are stored in the main office, which is locked when no one is present. Of the files inspected some of the service users records were out of date (as mentioned previously). Service users do have access to their records where this is appropriate. The table that was on landing during the last inspection has been moved; as a result there is easy access to the fire extinguishers. The registered person has consistently undertaken unannounced inspections to the home on a monthly basis in line with regulation and provided reports to the Commission for Social Care Inspection. The reports from the Commission for Social Care Inspection are on display in the office and were available for family members, other agencies and visitors to view. During the last unannounced inspection there were nine requirements made four of these have been either partly met or not met at all. Therefore, this places service users at risk. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 24 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 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 2 ENVIRONMENT Standard No Score 24 x 25 x 26 3 27 x 28 3 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 1 34 x 35 2 36 1 x x 1 x LIFESTYLES Standard No Score 11 x 12 X 13 2 14 15 16 17 x 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000027835.V275481.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beauly Way Score x x 1 x x x 3 x x 3 x Version 5.1 Page 25 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 YA6 Regulation Requirement Timescale for action 05/02/06 2. YA6 3. YA9 4. YA13 15(1)(b)(c) The registered persons are required to keep service user’s plan under review with consultation with the service user and/or their representative. This requirement is restated, a previous timescale of 30/08/05. 12(1)(a) The registered persons are required to ensure that prompt arrangements are made for move on of service users whose changing needs may be outside both the home’s ability to meet them and the homes statement of purpose. 12(1)(b) The registered persons are required to ensure that the requirements within risk assessments are fully implemented within the home to ensure service users health and well being. 16(2)(m) The registered persons must ensure that service users cultural and leisure activities take place as planned. If these do not take place then the specific reason must be recorded. DS0000027835.V275481.R01.S.doc 05/02/06 05/02/06 05/03/06 Beauly Way Version 5.1 Page 26 5. YA16 15(1) 6. YA17 17(2) sche 4 12 7. YA20 13(2) 8. YA20 13(2) 9. YA20 13(2) 10. YA23 18 (1)( The registered persons must ensure that the all “infringement of rights forms” are discussed with the service user and/ or family members or representative and signed by the above and staff in the home. This requirement is restated, a previous timescale 30/06/05. The registered persons must ensure consistent recording of the actual meal eaten when a Take away’ meal is provided. This requirement is restated, a previous timescale “at the next take away meal” following the previous inspection held on 17/06/05. The registered persons must ensure that the amount of medication held by the home are recorded on the current medication administration records are and carried forward each month to enable the home to evidence a clear audit trail of medication in the home. This requirement is restated, a previous timescale 14/06/05 The registered persons must ensure that the codes used on the medication administration records are recorded consistently and any omissions/additional recordings are accompanied with a written explanation, in order to evidence the reason. The registered persons must ensure that staff (including temporary staff) do not administer medication until they have received thorough training in the administration of medication and home can provide satisfactory evidence. The registered persons must DS0000027835.V275481.R01.S.doc 05/03/06 05/02/06 05/02/06 05/02/06 05/02/06 05/04/06 Page 27 Beauly Way Version 5.1 c)(i) 11. YA33 18(1)(a) 12. YA33 18(1)(b) 13. YA35 18(1) ( c)(i) ensure that all staff, including temporary staff receive appropriate training and mentoring in adult protection and have a clear understanding of the homes polices and procedures. The registered persons must ensure that at all times there are suitably competent and experienced persons working at the care home in such numbers as appropriate for the health and welfare of service users. The registered persons must ensure that the employment of temporary staff does not prevent service users from receiving continuity of care as is reasonable to meet their needs. The registered persons must ensure that temporary staff have received appropriate training and the details of such kept in the home. 05/02/06 05/03/06 05/04/06 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 Refer to Standard YA29 Good Practice Recommendations The registered persons should provide the one remaining service user with a photograph outside their bedroom. Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Beauly Way DS0000027835.V275481.R01.S.doc Version 5.1 Page 29 - 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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