Inspection on 05/09/07 for Benjamin House

This inspection was carried out on 5th September 2007.

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 no outstanding requirements from the previous inspection report, but made 12 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 09/05/07

Benjamin House 15/08/06

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 5th September 2007 09:30 Benjamin House DS0000009525.V344783.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.V344783.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.V344783.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 414506 healycare@ntlworld.com 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 vacant post Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Benjamin House DS0000009525.V344783.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 Date of last inspection Brief Description of the Service: Benjamin House is part of Healy Care, which consists of three terraced properties. An additional property is used an office facility. The properties are situated on the same road, 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 ten single bedrooms eight with en-suite toilets. Two of the bedrooms are situated on the ground floor. Staff are on duty to provide support 24 hours per day. Transport is occasionally available to enable service users to visit relatives and for outings within the community. Written information about Benjamin House, including the service users’ guide and last inspection report were available in the lounge of the home. At the time of the inspection visit the range of fees was between £455.00 and £1200.00 per week. Toiletries, hairdressing private chiropody was not included in the fees. There were voluntary optional charges for entertainment and transport. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Benjamin House on the 5th September 2007. The visit took 7 hours and was carried out by one inspector. The main focus of this visit was to monitor progress in responding to the previous requirements set by the Commission. Prior to the site visit, the registered person was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures in the home. The AQAA was not returned the Commission. The files/records of two people using the service were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living at the home. Discussion took place with the residents, acting manager(s) and staff. Various documents, including policies, procedures and records were looked at. Some of the accommodation and facilities were viewed. At the time of this inspection visit there were 9 people living in the home A random unannounced inspection had been carried out at the home on 5th July 2007. A letter following the random inspection will be made available on request, from the Commission to members of the public or other enquirers. What the service does well: People spoken with were happy with the meals provided, they explained how thy were involved with choosing menus, shopping and cooking. Several people had been supported to take a holiday, which they had very much appreciated. “we had a really good holiday” said one person. People were being given opportunity to get out into the local community and join in different activities. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 6 House meetings were being held each week, so people could voice their opinions and be asked about things which affected them. One person explained, “meals are picked for the week at the house meetings, we have a good selection” People were having some say in who worked at the home; records and discussion showed that people using the service had been involved with staff recruitment. Support was being provided to attend hospital and health care appointments. People spoken with were generally appreciative of the support provided by the staff team; one said “the staff are pretty good” What has improved since the last inspection? What they could do better: A manager must register with the Commission, to take legal responsibility for the day-to-day running of the home. Guidelines for protecting people from abuse were in need of changing, to make sure managers and staff do the right thing if there is a suspicion or an allegation of abuse is made. Individual care plans still needed to include full details of all their health, behavioural and emotional needs and how they are to be met, to ensure staff know exactly what to do for each person. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 7 Improvements were needed with medication practises, including staff training; to make sure people get their medication safely and at the right time. Individual risk taking was not being properly assessed and staff were not being given clear instructions on how to reduce or manage any risks. Better arrangements needed to be made, to make sure people living in the home have enough staff support for activities and outings in the community. More staff were needed to ensure there always enough staff on duty to provide proper support. To make sure people feel confident in making complaints, improvements needed to be made listening to what they say and dealing with their concerns and requests. To protect people living in the home, proper checks still needed to be carried out before letting staff start work in the home and new staff need to be given initial training. For the well-being and protection of people living in the home, staff needed to be trained in dealing with difficult behaviours. People living in Benjamin House, their relatives and others still must be formally asked if things are okay, to make sure the home is being run in their best interests. To show how improvements are to be made at the home, the owner needed to complete and send to the Commission a quality assurance assessment. Work needed to be carried out to improve a number of areas of the home for the well being and safety of the residents, for example making sure general maintence is carried out and carpets are kept clean. 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. Benjamin House DS0000009525.V344783.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.V344783.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service needs to show a continual improvement in ensuring all needs and abilities are properly considered and planned for, before people move into the home. EVIDENCE: There had not been any new people admitted to Benjamin House since the last inspection. Therefore the assessment and admission procedures and practices were unable to be fully assessed at this inspection visit. Previous inspection visits have shown new people have been supported to visit the home to meet residents and staff. However, there has been a lack of consistency in obtaining and making available to staff, appropriate assessment information and ensuring a plan of care is drawn up to meet all identified needs. The Commission expects the admission practices procedures will focus upon achieving positive outcomes for people ensuring that the facilities, staffing and specialist services provided by the home will meet the specific needs of the individual. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 10 The last inspection report and information about the home was seen to be available in the homes lounge. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 11 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): 6,7,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all practices and procedures were effective in ensuring people’s needs are properly responded to. EVIDENCE: Some progress had been made in reviewing and updating the residents individual care plans and each person had a plan in place, however, it was evident the deadline set by the Commission for meeting this requirement had not been fully met. The plans seen included some basic information necessary to deliver the resident’s care and support, but they were not detailed or used as working documents. They did not consistently reflect the care being delivered and did not provide staff with written important instructions on providing proper support, for example in response to their mental health. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 12 Observation of support practices showed people were being supported to make some choices and decisions in their daily lives. People spoken with had an awareness of their individual plans and some had signed in agreement with them. Some plans had limitations in relation to alcohol, smoking and financial matters; however, it was not always clear why or how these decisions had been made or agreed. Staff were not sure how to respond when people did not abide by their care plan agreements, which meant boundaries were unclear or inconsistent. The timescale set by the Commission for the service to ensure risk taking and responding to risk situations is properly managed, had not been met. The acting manager had updated one persons risk assessment and explained that this matter was in hand, however, there remained a significant lack of appropriate detailed assessment of risks, and the plans for staff to follow, for example, in response to violent behaviour, suicidal tendencies, self harm and going out independently. Consideration had not been given to the severity or likelihood of the risks; possible triggers had not been made known. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all practices and procedures were effective in promoting peoples’ skill development and providing opportunities to take part in community activities. EVIDENCE: People using the service were being some opportunity to take part in a variety of activities both within the home and in the community. The acting manager said two people were due to attend a course at the local college and another was considering a ‘taster’ course. He explained that he was looking towards introducing a more structured programme of activities. Some of the people living at the home had recently been on a holiday to Cleethorpes with staff support. Those spoken with said they had very much enjoyed their time away. People spoken with explained they were keeping in touch with members of their families and friends, by telephone, visits, or short Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 14 breaks away, some arrangements needed to be further clarified and agreed with individuals. Although regular house meetings were being held at Benjamin House, some people spoken with were still not confident that their suggestions and request would be acted upon. For example, additional shelving had been asked for in bedrooms but not provided and issues had been raised about people’s personal allowances being late in arriving at the home. Due to staff shortages, some support with community outings was not always being provided in response to peoples’ needs. Mention was made of a recent trip to Blackpool which appeared to have been poorly organised, with people saying they were upset about how the outing was managed. Staff indicated there were not always enough people on duty to provide support with group or individual activities. Records showed various meals were being provided to suite individual tastes, diets and preferences. Meals were provided at various times to fit in with peoples’ living patterns. All those spoken with were happy with the quality and variety of food provided at the home and explained the week’s menu was being discussed at the house meetings. Diets in response to cultural needs were being provided for. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 15 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): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Arrangements for managing personal needs, healthcare and medication did not always effectively support peoples dignity, health and well-being. EVIDENCE: People spoken with said they generally satisfied with the support provided with personal care, however, some matters still needed to be properly agreed and recorded in individual care plans. It was apparent from discussion and observation; people were generally being supported to take an interest in their appearance, hairdressing and clothing. Action had been taken to ensure a bathroom door locked properly, but some environmental matters had impacted upon peoples’ privacy and dignity, for example, one persons’ en suite shower was not accessible and another person had been sleeping on a mattress. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 16 Records showed contact with health care professionals such as GPs and CPNs (Community Psychiatric Nurses). People spoken with confirmed they had access to various health care professionals, including opticians and dentists. Support was being given to attend hospital appointments. Medication management practices and procedures were not fully assessed at this inspection. However, it was noted that progress had been made in providing staff with clearer instructions in relation to medication requiring specific procedures. Staff spoken with said there had not been training in this matter, but considered this was being pursued. Records showed one member of staff had previously attended a workshop on a particular medical condition. It was said individual guidelines for ‘when required’ and ‘variable dose’ medication, were soon to be devised. Benjamin House DS0000009525.V344783.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): 22,23 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Procedures and practices were not effective in supporting the complaints process, or promoting the protection of the people using the service. EVIDENCE: Some of the people spoken with expressed concerns about various matters at the home, they did not always feel their views were being properly listened to and dealt with by the homeowner. All those spoken with were aware they could contact the Commission with any concerns. A book was provided in the lounge for people to write any concerns, it was suggested this be replaced with a more confidential system. The Commission had recently received a complaint from an unknown source; this had been forwarded to the homeowner to investigate, some of the issues raised were looked at during the inspection visit. Records were not available of this or previous complaints, this meant there was nothing to show how the issues were being dealt with, or what action had been taken. The complaints procedure was on display in the hallway and copies had been placed in each person’s bedroom. The procedure was also included in the service user guide. The procedure on display did not include the contact details of the Commission or other agencies who may provide support. The procedure did not specifically tell people how to make a complaint, or explain the Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 18 complaints process, stating – “If you are unhappy about anything please tell us so that we can do something about it for you” Some of the details in the protection policy remained unclear and contradictory. For example, the policy stated “all reports of abuse, no matter how minor, should be immediately be investigated and acted upon by the person in charge…..It is the responsibility of the manager to ensure all accusations are followed through and investigated with or without consent of the person. All cases should be referred to social services without delay.” However, the policy then goes on to explain the action to be taken in the absence of consent, or of none involvement by social services or the police, in “line with the victims wishes”. Also, the over- emphasis in the policy of ‘investigating’ reports of abuse; raised questions on the appropriateness of exploring such matters, as apposed to obtaining basic details to then refer to the appropriate agencies for their attention. It was said the procedures would be reviewed and amended by the end of September 2007. One member of staff had previously received training in ‘conflict resolution’ this type of training was yet to be arranged for other staff members, a requirement had been made following the last inspection, for this training to be arranged by 27 July 2007. Staff spoken with expressed an awareness of safeguarding procedures, including reporting bad practice. Benjamin House DS0000009525.V344783.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, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People’s quality of life was not enhanced by their environment, as some parts of the home were unpleasant or in need of repair. EVIDENCE: The lounge continued to provide a pleasant room for the people using the service. New tables and chairs had been provided in the dining room. Action had been taken to improve the outside areas to the front of the home. Although the acting manager had taken action to make improvements at the home, including general repairs and upgrades. No progress had been made in cleaning dirty bedroom and en-suite carpets, the timescale for meeting this requirement had expired. Some people spoken with expressed dissatisfaction Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 20 with parts of the home, in particular the lack of shelving for storage and some decoration. One bedroom door lock was hanging off, a toilet roll holder had fallen off the wall and there was a shortage of suitable bins. Comments about the accommodation included, “It’s depressing me” and “It gets me in a bit of a mood”. The fridge in the kitchen was not working which meant people were having to use the fridge in the basement, this was inconvenient and presented as an increased health and safety risk, particularly as the light bulb in this area had blown. This matter was put right at the time of the inspection. One of the toilets/bathrooms was not in use; this had been reported to the homeowner at the end of July 2007. The flooring on one corridor had not been evened out, but the acting manager said this matter was in hand. It was apparent from maintence records that some matters had been attended to in good time, but this was inconsistent. Benjamin House DS0000009525.V344783.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): 32,33,34 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Staffing arrangements were not effective in aiming to ensure the peoples’ needs are properly and safely met. EVIDENCE: Positive interactions were observed between the service users and staff. People spoken with were generally appreciative of the support provided by the staff team. There was some good practice with staff recruitment, people using the service had been involved in selecting staff, which meant they had some say in who worked with them. There was no manager on duty at the time of the visit. There were two support workers on duty, both said they were not in charge and did not have management responsibility for the home. The staff rota showed that staff hours were not always being covered, for example when staff were absent due to sickness. The acting manager was off but the hours had not been covered. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 22 This meant people using the service were not always being properly supported with activities and outings, or with one to one support. There were not enough staff available to sufficiently cover the rota. Weekly staff rotas were being devised the day before they commenced, which meant staff were not being given much notice of their expected shift patterns. The recruitment records of the newest member of staff were examined, most checks had been properly carried out, however, the application form did not ask for dates of attendances at schools and colleges, therefore education history could not be properly checked out and a full employment history had not been recorded or the gaps explained. The induction training records of new employee were unable to be located, and the staff member had not read and signed the fire record book, which included basic fire safety training. The acting manager said individual staff training records were in the process of being updated. Benjamin House DS0000009525.V344783.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 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living in the home did not benefit from consistent, effective leadership and management of the service. EVIDENCE: The Commission for Social Care Inspection has serious concerns regarding the operation and management of Benjamin House. There is evidence of historical erratic performance at the home which has lead to a lack of sustained improvement over time. This inspection visit showed that a number of requirements had not been addressed and therefore action to address these areas remained outstanding. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 24 Since the last key inspection another acting manager had been appointed at Benjamin House. There have been several acting un-registered managers who have stayed at Healy house for varying lengths of time. Although some improvements had been made, evidence included within this report indicates shortfalls in relation to the management and daily running of the home. There has been a long standing requirement for a manager to be appointed at the home and to be registered with the Commission for Social Care inspection. At the last inspection a requirement was made for a suitable manager to apply for registration with the Commission by 27th July 2007, the acting manager was said to be in the process of completing the application. At the time of the inspection visit, the acting manager was off duty; proper arrangements had not been made for another person to take on management responsibilities for the home. The homeowner was contacted and an acting manager from another home in the organisation attended Benjamin House, to take part in the inspection process. The acting manager for Benjamin House called in for a short period of time, and explained his actions and intentions to improve matters at the home. Staff spoken with felt the home’s acting manager was working hard to ensure the home was properly run. The AQAA (Annual Quality Assurance Assessment) had not been completed and returned to the Commission prior to the inspection visit, and was not made available during the inspection. It is a legal requirement to complete and return this assessment to the Commission, to provide information about the service and plans for improvements. House meetings provided some opportunity for people living at the home to be consulted and voice their opinions. Documentation was not available to show that installations and equipment, such as electrical wiring and gas appliances had been serviced. The testing of portable electrical appliances was overdue. Records showed staff had received some training in safe working practices, including First Aid and Basic Food Hygiene. Some general health and safety risk assessments had been carried out. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 25 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 The CHOICE OF HOME Standard No Score 1 X 2 2 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 1 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 X 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 2 14 2 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 1 X 1 X X 2 X Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(1) Requirement To make sure people receive proper care and support, service users plans must include all identified needs and provide clear detailed instructions for staff, on how to meet these needs. Timescales of 29/09/06 and 20/07/07 not fully met. To make sure people are supported as safely as possible, risk assessments and risk management strategies must be completed in response to service users behavioural needs. Timescale of 20/07/07 not fully met. To make sure people are properly and safely supported with their medication, all staff assisting with medication requiring specific procedures; must be suitably trained and assessed as competent to provide this assistance. Timescale of 29/06/07 not met. To make sure complaints are effectively managed and dealt DS0000009525.V344783.R01.S.doc Timescale for action 02/11/07 2. YA9 13(4)(c) 02/11/07 3. YA20 18(1)(c)(i) 02/11/07 4. YA22 17 (1) 11/10/07 Benjamin House Version 5.2 Page 27 5. YA24 23(b) 6. YA30 23(2)(d) 7. YA33 18(1)(a) 8. YA34 19(10)(b) 9. YA35 18(1)(c)(i) 10. YA35 18(1)(c)(i) 11. YA37 8(1)(b)(iii) with, clear records must be kept of the issues raised and action taken in response. To make sure people have a safe and comfortable environment, arrangements must be made to ensure the home is kept well maintained and in good order. Timescale of 22/06/07 not fully met. To make sure people live in pleasant, hygienic surroundings, arrangements must be made to keep all parts of the home clean and action taken to thoroughly clean carpets. (Timescales of 27/10/06 and 13/07/07 not met) To make sure people are properly supported, action must be taken to ensure there are enough suitably qualified and experienced staff to work in the home. Timescale of 04/08/08 not met. For the protection of people using the service, staff recruitment checks must include full employment history and a written explanation of any gaps in employment. To ensure new staff are properly trained, they must undergo a structured induction training programme. For the protection and well being of people living in the home, arrangements must be made to train staff in dealing with challenging behaviours. Timescale of 27/07/07 not met. To make sure the home is effectively managed, a DS0000009525.V344783.R01.S.doc 11/10/07 11/10/07 02/11/07 02/11/07 02/11/07 02/11/07 02/11/07 Benjamin House Version 5.2 Page 28 12. YA39 24(1) suitable manager must apply for registration with the Commission. (Timescales of 05/05/06, 29/09/06 and 27/07/07 not met) To show how improvements are to be made at the home, the registered person must complete and return to the Commission, the Annual Quality Assurance Assessment. 02/11/07 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 YA9 Good Practice Recommendations To make sure a reasonable balance is achieved between independence and personal safety, risk assessments and management strategies should be further developed to include all activities, which may affect the health or wellbeing of people using the service. To make sure people get their medication as and when they need it, clear criteria should be defined on an individual basis, when service users are prescribed when necessary and variable dose medication. The arrangements for enabling people to raise concerns and complaints should be reviewed and developed to ensure their opinions and views are properly listened to and where possible acted upon. To ensure peoples’ rights to raise concerns are promoted and supported, the complaints procedure should more clearly specify the process for making complaints. The Safeguarding adults Procedure needs amending to ensure that staff have clear directions of the actions they should take should a suspicion, incident, or allegation of abuse come to their attention. Staff should continue to be supported to undertake appropriate training, as specified by the National Minimum Standards for Younger Adults, so they have the appropriate skills and knowledge to support people living in the home. DS0000009525.V344783.R01.S.doc Version 5.2 Page 29 2. YA20 3. YA22 4. YA23 5. YA32 Benjamin House 6. YA33 7. 8. 9. 10. YA34 YA35 YA35 YA42 To ensure people are properly supported, staffing arrangements should ensure a member of staff is always on duty to manage the home. On call systems should not rely upon staff working in other homes in the organisation. To provide more accurate information, clearer records should be kept of new employees start dates. To show new staff are being properly trained, induction training records should be readily available in the home. To ensure people using the service receive appropriate care, all support staff should be enabled to undertake appropriate mental health training. Documentation to show the servicing of equipment and appliances should be readily available in the home. Benjamin House DS0000009525.V344783.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Benjamin House DS0000009525.V344783.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. 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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