Inspection on 15/08/06 for Benjamin House

This inspection was carried out on 15th August 2006.

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

Other inspections for this house

Benjamin House 26/03/08

Benjamin House 05/09/07

Benjamin House 09/05/07

Benjamin House 15/03/06

Benjamin House 28/07/05

Benjamin House 06/12/04

Benjamin House 27/04/04

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

CARE HOME ADULTS 18-65 Benjamin House 41 Ormerod Road Burnley Lancashire BB11 2RU Lead Inspector Mr Jeff Pearson Unannounced Inspection 15th August 2006 09:30 Benjamin House DS0000009525.V299333.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 Benjamin House DS0000009525.V299333.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. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Benjamin House Address 41 Ormerod Road Burnley Lancashire BB11 2RU 01282 835926 01282 414500 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) Mrs Bridget Mary Healy Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The home will accommodate up to 10 adults up to the age of 65 years who have mental health problems 15th March 2006 Date of last inspection Brief Description of the Service: Benjamin House is part of Healy Care Dispersed Home Scheme which consists of three terraced properties. An additional property is used an office facility. The properties are situated on the same rood, in what is primarily a residential area. Benjamin House is close to the resources available in Burnley town centre. It is registered to accommodate 10 adults under the age of 65 with a mental illness. The accommodation available is homely and domestic in style. There is a lounge, a room for smoking and a dining kitchen with conservatory area. There are six bedrooms (four with en-suite toilets) and two twin bedrooms. Work to further develop the accommodation was being carried out. Staff are on duty to provide support 24 hours per day. Transport is available to enable service users to visit relatives and for outings within the community. At the time of the inspection visit the range of fees was between £450.00 and £1000.00 per week. Toiletries, hairdressing private chiropody were not included in the fees, there were voluntary optional charges for entertainment and transport. The service users’ guide and last inspection reports were available in the lounge. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took 7 hours and was carried out one day by two inspectors. There were 6 service users accommodated. The files/records of 3 service users were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. The records of the most recently recruited staff were looked at. During the inspection, four residents, the person in charge and staff were spoken with. A tour of the premises was carried out. Some policies and procedures were looked at. Prior to the inspection visit, survey forms were sent to the home for the residents and their relatives/representatives to complete, three were received from residents. Information was gathered from a pre inspection questionnaire completed by the acting manager. What the service does well: The atmosphere in Benjamin House was relaxed, supportive and friendly, relationships amongst every one seemed generally good. One resident said “Everything is okay” “Things are alright” said another. Residents’ meetings were being held so people could be involved in making decisions. People living at Benjamin House were involved with different activities and were getting out into the community “I’ve been busy” explained one person. The lounge and dining area provided comfortable living areas for residents. Most people said they were happy with the accommodation provided; some rooms had en suite facilities and good furnishings. One resident explained he was looking forward to moving into a ‘new’ room. People were being supported to keep in touch with families and take short holidays, which provided a break from day to day living. Everyone was happy with the meals provided, people were involved with choosing menus and cooking. “The meals are good, we get involved with cooking and shopping” one person said. Meal times were flexible, to encourage individual lifestyles. Healthy eating was being encouraged. Staff were keen to do a good job, they got on well with people living in the home. All surveys completed by residents indicated that staff treat them well. “I like the staff” said one person; “I feel I have come on very well, since I have been at Benjamin House” another wrote. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: This inspection showed little progress had been made in improving the service at the home. There were 12 outstanding requirements from previous inspections and 6 additional requirements. The homeowner therefore needed to take action to improve matters at Benjamin House, for the benefit of service users and staff. A manager must register with the Commission, to take legal responsibility for the day-to-day running of the home. So people know their responsibilities and rights, the house rules should be reviewed and agreed with service users and staff. To make sure people’s medication is managed as safely as possible, clear individual guidelines should be written telling staff when to offer when required medication, staff needed to complete training and medication guidelines still needed updating to provide clear up to date instructions. Guidelines for protecting people from abuse were still in need of changing, to make sure managers and staff do the right things. Some bedrooms needed more things, unless people agreed they didn’t want or need them. Information about people living in the home and Plans showing staff how to provide support to individuals needed improvement; to make sure people are properly treated and get the support they need. Plans needed to be kept under review. More attention must be given to people taking risks and how staff should respond to these situations. To protect people living at Benjamin House, proper checks needed to be carried out before letting staff start work in the home. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 7 So new staff know the basics of their job, they must be given proper training on their first day and onwards. Staff training needed to continue in first aid, health and safety, food hygiene, mental ill health and NVQ training (National Vocational Qualifications) People living in Benjamin House, their relatives and others must be formally asked if things are okay, to make sure the home is being run in their best interests. Work to improve areas of the home was ongoing; this needed to continue. To make sure everything in Benjamin is as safe as possible, the home must be properly managed and all areas and routines must be carefully considered to reduce the risk of harm to people living there, staff and visitors. 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. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Initial assessment details were incomplete or not available, so it was not clear if peoples’ needs had been fully assessed or that they could be met at the home. EVIDENCE: No new residents had been admitted since the time of the last inspection. Therefore it could not be seen whether the initial assessment process had been improved. The current residents files looked at did not include their initial assessment details. A resident from another home in the company had spent the previous night in the home, there was no evidence to indicate this arrangement had had been appropriately agreed, or responded to as a new admission and raised questions about the suitability of the placement in the other home. Benjamin House DS0000009525.V299333.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents assessed needs and goals were identified in their plan of care and they had agreed to these. Residents were encouraged to make choices and decisions; this meant that they had some control over how they were supported and how they lived their lives. Not all potential risks were identified and staff did not have enough directions on how to manage these. EVIDENCE: The files for three residents were looked at. These showed that the personal, health and social care needs were identified. The directions to staff on how to meet these needs were not precise. For example, many goals stated, “to increase independence” but did not tell staff exactly how to do this. This lack of precise directions to staff meant that there was the potential for inconsistencies to occur in the support given. The records relating to a resident’s status under the Mental Health Act 1983 were unclear. There was Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 11 nothing in the plan of care to tell staff about this and therefore, no information about their responsibilities. The plans seen had been signed by the residents. The plans stated that they were due to be reviewed in March 2006 but there was no record of this having been done. The care planning process showed residents were being supported to make choices and decisions in their daily lives. Care planning considered people as individuals and therefore dealt with diversity matters, this approach was also observed in support practices. One of the plans had details on a restriction agreed to by the resident. Where residents did not manage their own money records were kept of the amounts deposited and withdrawn and receipts kept for items purchased on their behalf by staff. There was a risk assessment in the residents’ files but this did not cover all risks. For example, some residents were observed to go into the community independently. This was not properly risk assessed. The risk assessment did not indicate what the level of risk was, whether it was a high, medium or low risk, and did not inform staff on how to minimise or manage this. The risk assessments seen had not been reviewed in the last 10 months. Benjamin House DS0000009525.V299333.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were being offered opportunities to engage in a range of activities, they were supported to use community resources. Independence was being promoted and rights were being respected, not all responsibilities had been properly agreed. The catering arrangements were sufficient in providing for the residents tastes, choices, diets and skill development. EVIDENCE: Residents spoke of the various activities, both in and out of the home, including clubs, college, project work, day centres, pubs, flee markets, sports/fitness centres, shopping and TV. During the inspection some service users went out into the local community. Those spoken with explained they were keeping in touch with members of their families and friends, by Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 13 telephone, visits, or short breaks away. Some had been on a short holiday earlier in the summer. The house rules were displayed in the home, they had been written some time ago; some matters such as respecting others had not been included. Records showed house meetings were being held to discuss group matters including outings and activities. There were no details in the plans of care about the residents’ responsibilities with regard to housework, which included responsibility for their own bedroom and other household task such as cleaning communal areas and cooking. It was unclear whether one resident was still on restrictionms under the Mental Health Act 1983. There was no indication in the plan of care whether this person had been given information about their right to appeal against the section and how to go about this. Mealtimes were flexible, depending what was happening in the home. Residents made drinks and snacks for themselves and said they could get involved with shopping and cooking. Everyone was happy with the meals provided. Healthy eating was being encouraged, fresh fruit and vegetables were available. Records showed the diet being taken by individuals. The weeks menu was being discussed in house meetings. Specific diets were being catered for. Benjamin House DS0000009525.V299333.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Daily routines were flexible and therefore, met the needs of residents. The lack of precise directions on how to meet their personal and healthcare needs meant that these may not be fully met. Medication management practices were in need of improvement for the protection of the residents and staff. EVIDENCE: Service users personal care support needs were highlighted in their individual plans as appropriate, this support was observed to be provided sensitively and discreetly, there were both male and female staff working at the home to provide assistance. Routines of daily life were flexible and residents were able to make decisions about their lives, including what time they got up and went to bed, and when they had some meals. Health care needs were also identified. There were some elements of good practice seen, for example, the inclusion of specialist health professionals in Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 15 the care of residents. However, the directions available for staff were not always precise in how to meet needs or sufficient in detail for staff to know exactly what actions to take. For example, how various physical conditions were to be managed. Weight reduction programmes did not show a recent record of weight, or any indication of what weight was being aimed for. Health monitoring took place and included GP visits and eye tests. Medication storage facilities were satisfactory. Individual risk assessments had been completed with residents on managing their own medication. The medication for one resident who self-administered was checked and was found to be stored securely. Records were clear and up to date. The medication management policies and procedures had not been revised and updated to include current good practice. There was no information to staff on: the ordering procedures; what to do if a resident consistently refused medication; and what to do if there was a medication error. There was good practice in relation to the management of a resident’s medication for home leave. However, this was not covered in the policies and procedures. Medication training was being done by those staff who had responsibility for administering medications but had not yet been completed. There was still no policy or individual protocols for when necessary or variable dose medication. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 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): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure provided guidance on making complaints. No progress had been made in updating the protection and abuse policies and procedures; this may result in abuse matters not being properly dealt with. EVIDENCE: The complaints procedure was in the service user guide; this included the appropriate referral details and the contact details of the Commission. Systems were in place to record and follow up complaints. Residents had an awareness of the complaints procedure but said most issues were raised and discussed, in the weekly house meetings. Staff spoken with expressed an understanding of how to deal with complaints. There was a book in the lounge for residents to write down any complaints, it was not clear if the last issue had been followed up. The record to did not promote confidentiality. The protection/abuse policies and referral procedures seen had not been revised and updated, they included inappropriate details about consent issues. The staff whistle blowing policy seen had not been updated. Staff spoken with had an awareness of protection and reporting bad practice issues. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home were in need of attention to improve the living environment for the residents. EVIDENCE: The lounge provided a pleasant environment for the residents; there was good quality furniture and a telephone with mobile handset was available. The dining room/conservatory provided a useful space and stored various games and books; a computer with Internet access was available. The kitchen was domestic in style and accessible to the residents. Work was ongoing to provide some bedrooms with better facilities. A new toilet was being created. There was no written programme of refurbishment or renewal. The homeowner had not provided written assurances to the Commission about improving the home. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 18 There was some outside space to the side and rear of the home, where residents could sit. The front garden was overgrown with weeds. Parts of the home including one bathroom and some bedroom carpets were unclean. The laundry provided suitable facilities, but was being used to store old bed bases and mattresses. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 19 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): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing arrangements were not entirely satisfactory in providing service users with effective and consistent support. Recruitment practices showed full attention was not being given to protecting the service users. Staff training and development was ongoing. EVIDENCE: There had again been some changes in staff. The two support staff on duty at the inspection visit had been employed at the home for three months; they had no previous experience of care work, but interacted well with the service users, and appeared well motivated and enthusiastic. Service users made positive comments about the staff team. The senior support worker, described as being ‘in charge’ had been at the home for three days. In total there were six support workers and a house manger employed to work at Benjamin House. Staff spoken with confirmed the agreed staffing levels were being maintained and this was reflected in the records seen. Staff files were not readily available in the home; the most recently recruited persons’ file was unable to be located. Staff records had some required details missing for example; they did not include declarations about previous Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 20 convictions, dates of education/further education had not been requested, medical declarations did not include sufficient information to make an informed judgement about health matters; in particular details about mental health issues had not been requested. One staff record did not include a full employment history; one CRB (Criminal Record Bureaux) statement was not available. Staff spoken with said training and development was ongoing, evidence was seen of training completed, ongoing and planned for. Records were again seen of structured induction training for the new staff. But initial basic instruction was not being appropriately given, for example initial orientation induction had not been completed on the first day of work. One senior support worker had attained NVQ (National Vocational Qualifications) Level 3 in care, two support workers were undertaking NVQ level 2 and two support workers had enrolled on NVQ level 2. The house manager and senior support worker were due to commence Approaches to Mental Health training. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 21 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): 37,39,40,41,42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management arrangements were lacking in providing continued stability, organization and direction for the service users and staff. Improvements were still needed to show the home was being properly reviewed and developed. EVIDENCE: Since the last inspection visit, changes had again been made in the management team of Benjamin House, the previous house manager, had transferred to another home in the organisation. The deputy manager had become acting manager. At the inspection visit, the acting manager was not on duty, so the previous house manager came to the home to participate in the inspection process. There were several requirements and recommendations outstanding from previous inspections, including a breach in conditions of registration to employ Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 22 a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Mary Healy, registered provider had not provided the Commission with an action plan to show how improvements were to be made at Benjamin House. The previous house manager was not sure aware of any progress made in quality assurance matters. Residents spoken with said they were not aware of any quality assurance surveys. There was no annual development plan available. Policies and procedures were still in the process of being reviewed and up dated. The pre inspection questionnaire suggested some key policies and procedures were not in place. Some of the homes policies, for example on recording were not being followed. Records showed fire equipment was being tested and fire drills had been carried out. Fire risk assessments had previously been completed by an outside agent. The mattresses and bed bases stored in the laundry presented as a fire risk. The electrical wiring certificate was seen to be up to date; evidence was seen of portable electrical appliance testing. The gas systems servicing statement was out of date. Training in safe working practices was being arranged or ongoing, but not all staff had completed all topics. There were no proper health and safety risk assessments in place. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 23 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 1 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 1 X 1 2 2 2 X Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA2 Regulation 14,17 Requirement Records of service users initial assessments must be kept available in the home. (Timescales of 01/09/05 and 05/05/06 not met) All of the resident’s needs in respect of their health and welfare must be identified in their plan of care. This must include information relating to their status under the Mental Health Act 1983. The plan of care must be kept under review. This must be done at least every six months or more frequently if needs change. Risk assessments/management strategies must be completed on service users engaging in activities which may affect their health or well-being. (Timescale of 01/09/05 and 12/05/06 not met) The risk assessments must include the level of risk and be regularly reviewed as part of the care planning process. All staff responsible for dealing with medication must receive accredited medication DS0000009525.V299333.R01.S.doc Timescale for action 15/09/06 2. YA6 15(1) 29/09/06 3. YA6 15(2)(b) 15/09/06 4. YA9 13 15/09/06 5. YA20 13 24/11/06 Benjamin House Version 5.2 Page 25 6. YA20 13,17 7. YA23 13 8. YA24 16,23 9. YA26 12,16,23 10. YA30 13,16,23 11. YA34 17,19 management training. (Timescale of 01/10/05 and 07/07/06 not met) Medication management policies and procedures must be in accordance with current recognised guidelines and legislation (Timescale of 01/10/05 and 12/05/06 not met) The protection and abuse policies must be amended to include appropriate details for responding to suspicions, allegations, or incidents of abuse or neglect. Staff must be made aware of these procedures. (Timescale of 01/09/05 and 12/05/06 not met) The home must be refurbished to a satisfactory standard. (Timescale of 01/10/05 and 28/07/06 not met) All service users bedrooms must include the minimum furnishings as outlined in standard 26 of the National Minimum Standards for Younger Adults, unless otherwise agreed. (Timescale of 01/10/05 and 12/05/06 not met) Arrangements must be made to keep all parts of the home clean and action taken to thoroughly clean bedroom carpets. The recruitment practices must include the obtaining of required information for all staff. Including full employment histories must be sought and records kept of gaps in employment. CRB (Criminal Record Bureaux) checks must be readily available. (Timescale of 05/05/06 not met) Medical declarations must include mental ill health. Applicants must be required to DS0000009525.V299333.R01.S.doc 27/10/06 27/10/06 24/11/06 24/11/06 27/10/06 15/09/06 Benjamin House Version 5.2 Page 26 12. YA35 18 13. YA37 8 14. YA39 24 15. YA42 13,23 16. 17. 18. YA42 YA42 YA42 13,23 13,23 13 declare any convictions and cautions. All staff must undertake an appropriate programme of induction training. (Timescale of 05/05/06 not met) A suitable manager must apply for registration with the Commission. (Timescale of 05/05/06 not met) A formal system for reviewing and improving the quality of care provided at the home must be implemented. (Timescale of 01/10/05 and 26/05/06 not met) All safe must receive training in safe working practices, as specified in standard 42.2 of the National Minimum Standards for Younger Adults. (Timescale of 21/07/06 not met) Action must be taken to remove the mattresses and beds from the laundry area. Arrangements must be made for the boilers and central heating systems to be serviced. Health and safety risk assessments must be carried out on all areas of the home and outside grounds. Matters identified as a result of health and safety risk assessments must be attend to. 15/09/06 29/09/06 29/09/06 24/11/06 08/09/06 29/09/06 29/09/06 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 YA1 Good Practice Recommendations The service user guide should be produced in a more ‘user DS0000009525.V299333.R01.S.doc Version 5.2 Page 27 Benjamin House 2. 3. 4. 5. 6. 7. YA2 YA16 YA16 YA19 YA20 YA22 7. 8. 9. 10. 11. YA23 YA24 YA32 YA34 YA37 12. YA40 13. YA41 friendly’ version. Copies of letters to service users confirming the home can meet their needs should be kept on service users files. The house rules should be reviewed and agreed with the service users. There should be evidence to indicate that residents have had their rights under the Mental Health Act 1983 explained to them. The directions in the plan of care should tell staff precisely what to do in order to meet the residents’ needs. Clear criteria should be defined on an individual basis, when service users are prescribed when necessary and variable dose medication. A more confidential system for enabling residents to make complaints should be introduced. The complaints procedure should be discussed with service users periodically. It is recommended managers and staff receive suitable training in receiving and investigating complaints. All staff should receive training on protection and abuse and dealing with challenging behaviour. The gardens should be kept well maintained. Staff should continue to be supported to undertake appropriate training, as specified by the National Minimum Standards for Younger Adults. The staff recruitment application form should be updated to ensure all appropriate details are recorded and responded to. The manager should be provided with a job description which clearly indicates designated duties and responsibilities, in relation to the Care Home Regulations and National Minimum Standards. Policies and procedures should be reviewed and up dated in line with current good practice and in accordance with Appendix 3 of the National Minimum Standards for Younger Adults. The various recording systems for service users, should be streamlined to reduce unnecessary duplication. Benjamin House DS0000009525.V299333.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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. 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