Inspection on 10/04/06 for George Beal House

This inspection was carried out on 10th April 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 but made no statutory requirements on the home.

Other inspections for this house

George Beal House 18/04/08

George Beal House 19/04/07

George Beal House 29/11/05

George Beal House 16/04/05

George Beal House 04/10/04

George Beal House 17/04/04

George Beal House 08/03/04

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

CARE HOME ADULTS 18-65 George Beal House Off Williamson Road Kempston Bedford MK42 7HL Lead Inspector Rachel Geary Unannounced Inspection 10th April 2006 13:55 George Beal House DS0000033055.V289366.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 George Beal House DS0000033055.V289366.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. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service George Beal House Address Off Williamson Road Kempston Bedford MK42 7HL 01234 857300 01234 843225 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) Bedfordshire County Council Mrs Violet Ntombizodwa Masters Care Home 16 Category(ies) of Learning disability (16) registration, with number of places George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Care Home Category: LD - Learning Disability (Long stay) (10) Category: LD - Learning Disability (Respite) (6) Period of stay for respite service users - maximum six weeks Gender: Male and Female Age: over 18 years Service Users may also have additional physical disabilities Date of last inspection 29th November 2005 Brief Description of the Service: George Beal House is a local authority care home providing long term residential accommodation for ten adults with profound, multiple disabilities (learning and physical). The home also provides respite care for up to six adults at a time. The home is situated in Kempston town in close proximity to local facilities and transport routes. The building consists of three interlinked bungalows, each with its own lounge/dining area, bedrooms, bathrooms and kitchenette. In addition, there is a shared lounge, link area, sensory room, laundry facilities, staff rooms/offices and an industrial kitchen. A good-sized sensory garden surrounds the building, and there is parking space to the front of the home. The organisation of the home and building is institutional in a number of aspects, and the long-term plan is to reprovide this service. At the time of writing, there were no known timescales for this to happen. The home has developed some user-friendly documents for current and prospective service users. Information regarding the home’s fees, including any additional charges, was not known at the time of writing. George Beal House DS0000033055.V289366.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, and took place from 13.55 to 19.45. The inspector met service users, spoke to staff on duty - including the resource manager and manager, looked at records, and had a partial tour of the premises. Service users had little or no verbal communication skills, and could only provide limited information about the care they received. Because of this, the inspector spent the majority of the inspection in ‘A’ bungalow, which is one of the long stay bungalows, to observe the care being provided. At the end of the inspection, some written feedback was left for the manager. By the time of writing, a response had been received, and this has been included throughout this report. What the service does well: What has improved since the last inspection? What they could do better: The timescales for a number of the previous inspection requirements have not been met, and have now expired. To this end, revised timescales have not been given within this report. It is paramount that these are now addressed as George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 6 a matter of urgency, or the Commission for Social Care Inspection will be minded to take further action in order to bring about compliance, in accordance with the legal responsibilities of the Registered Provider. Care plans and related paperwork, still need further work to provide sufficient information for staff to meet the holistic needs of all service users, particularly the respite service users. As previously reported, despite the limitations of the current environment, consideration must be given to improving service users’ opportunities to develop their individual skills, and enjoy more sensory experiences associated with every day home life and ordinary living principals. Finally, the service must continue to develop current paperwork and systems for staff and service users, to make sure that they are meeting legal requirements, and the Government’s standards for services such as George Beal House. 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. George Beal House DS0000033055.V289366.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 George Beal House DS0000033055.V289366.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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Prospective service users are admitted following a comprehensive assessment process. And, the home has developed some useful information to enable prospective service users and their representatives, to make an informed decision about the services offered at the home. EVIDENCE: As previously reported, information regarding the home’s assessment procedure is included in the Statement of Purpose. In addition, there was evidence that appropriate and detailed information was being obtained prior to admission. As stated previously, the home had developed a Service User Guide, and a Service User Contract. Both documents were illustrated with pictures to help service users to understand them. At the last inspection, there had been no evidence that either of these documents had been provided to respite service users. A member of staff explained that these had now been sent out, and that service users and their families were in the process of returning signed copies of the contract. George Beal House DS0000033055.V289366.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, 7, 8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A number of factors from this inspection, suggest that service users’ holistic needs and choices are not adequately promoted, or met. EVIDENCE: George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 10 At the previous inspection, the resource manager, Stuart Tripcony, had said that service user files and paperwork were in the process of being updated. Some good examples of service user plans and related paperwork were seen on this occasion. Attempts had also been made to make ‘secondary care plans’, for each service user, more user friendly. However, once again, some inconsistencies were noted. A sample of service user records indicated that the respite* bungalow still had the most work to do in this area. Some examples included: incomplete or inadequate care plans, disorganised storage and inconsistencies in the records held in each file, missing information, and a lack of measurable personal goals – linked to outcomes from the most recent review**. It was said that staff did not always have enough time to carry out their administrative tasks. *There were approximately 23 service users accessing the respite bungalow at the time of this inspection. **There was evidence that service user reviews were in the process of being completed. There was evidence that some recent environmental works had negatively impacted on service users. It was said that during the works, two service users from the respite bungalow had been placed in ‘A’ bungalow, a long stay bungalow, because there had been no electrics in the respite bungalow. The CSCI had not been notified of this incident at the time, and it was further discussed how two of the four service users from ‘A’ bungalow had been affected as a consequence. There was no evidence that service users had been consulted about the arrangement. During the works, the CSCI had been aware that a small number of respite service users had needed to access the bathrooms in the long stay bungalows. During this inspection it was discussed that the refurbishment works could have been managed better, and that the arrangements stated here, should be the exception, rather than the rule. The home had a call-bell type monitoring system in each bedroom, which is used at night time. It was discussed that at times, the system could ‘back up’ and that the sound from one service user’s bell, could be heard in another service user’s bedroom. It was said that one service user had indicated that they wanted the system to be switched off in their room. However, because there are only two waking night staff at night for the three bungalows, it was also said that the night staff depend on the monitoring system being left on, and that service users’ preferences cannot always be taken into account. It was suggested that increasing the number of waking staff at night, would promote service user choice in a number of areas. See also ‘staffing’ section of this report. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 11 Once again, a sample of service user files indicated that there was limited up to date risk information in place for respite service users, whilst a number of assessments were in place for the long stay service users. Some were due for a review. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 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 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is limited evidence that all service users have regular access to a variety of meaningful activities. And, choice and participation arrangements for service users with regard to meals, continue to be poor. EVIDENCE: It was previously reported that respite service users were not accessing community facilities and external activities on a regular basis. Records indicated that this was still the case on this occasion. The records for one service user listed: bedtime story tape, socialising with peers, lie in, relaxing on bed, watching ‘Stars in their eyes’ final, listening to the radio, a retirement party, a hand massage, and sitting in the garden, as the activities for the previous month. The weekly activities for two long-stay service users were also examined. The first service user reportedly refused to participate in a structured day care programme, and the manager stated that the person went out regularly for swimming and lunch. This was not verified on this occasion. It was said that George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 13 the second person, who did want to participate in a structured day care programme, was unable to. A member of staff explained that the person had ‘slipped through the net’ in the transition from college to full time residential accommodation. To this end the person attended some external day-care activities for an approximate total of 2 days per week, and spent the remainder of their time at the home. The home had still not provided telephone points in bedrooms, or a designated telephone for use by service users. The resource manager had previously stated that the home had a mobile phone that service users could use to make private calls however; staff often needed to use this when working away from the home. The manager acknowledged on this occasion, that the current phone system was out dated, and that a request for a new phone system had been made, in order to provide service users with access to a private phone at all times. Otherwise, there was evidence that service users are encouraged to maintain contact with families, friends and advocates, as appropriate. As previously reported, due to a lack of adequate facilities within the individual bungalows, meals were being prepared in a central industrial kitchen. A member of staff confirmed that external suppliers still delivered food to the home in bulk, and that meal times were arranged to fit in with the cook’s shifts. There were still limited opportunities therefore, for service users to participate in the day-to-day running of the home, including meal planning and preparation. One service user, who was able to move about independently, was observed being encouraged to place their cup in a kitchenette sink after use however. The resource manager said that there were health and safety implications regarding service users accessing the main kitchen. See also ‘environment’ section of this report. Once again, it was noted, that neither staff nor service users knew what the evening meal was, until a hot trolley was brought into the bungalow. As previously reported, there was only one choice of meal. It was discussed that if service users did not like the meal on offer, then they would only be offered a snack such as soup, or a sandwich as an alternative. Appropriate support was provided to service users who required assistance with feeding. Since the last inspection, a meeting was held between representatives from Beds County Council, and the CSCI, to discuss a number of generic and specific service issues. At this meeting, it was acknowledged that work to create better opportunities for service users, within the restraints of the current environment, was required, and possible. One operations manager also highlighted the importance of doing so, for service users who may wish to move onto more individual/independent accommodation in the future. George Beal House DS0000033055.V289366.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): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ personal and health care needs are adequately met. However, some aspects regarding medication need to be improved to ensure the safety and well-being of the service users. EVIDENCE: Staff were observed to deliver support in a respectful and unhurried manner. Although, there was evidence that service routines and constraints, sometimes impacted on service user preferences. See also ‘staffing’ section of this report. Records for a long stay service user indicated that service users’ health care needs are addressed within care plans, and related documentation. There was evidence that staff understood the individual needs of service users, and that written guidelines and information were being followed. Service users in ‘A’ bungalow did not require medication during this inspection however the MAR (medication administration records) and medication storage was examined. There were two medication cabinets for ‘A’ bungalow. One appeared to contain new stock – although two open medication boxes were George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 15 found. One of these boxes contained a box of medication prescribed for another service user. The following were then found in the other cabinet: handwritten alterations to a pharmacy label, liquid medication that had been prescribed 30.9.05 with no clear expiry date, medication waiting to be disposed from a month earlier, a lubricant that had been prescribed for a named person 7.7.05, but was being used for a service user in ‘A’ bungalow*, and suppositories that had expired 34 months previously. *The manager stated after this inspection that this matter would be investigated. MAR sheets that were examined appeared to be in good order however, with clear reasons for the administration of PRN medication. It was noted that the only permanent member of staff from ‘A’ bungalow, was required to support another bungalow with medication administration after dinner. This left 1 agency member of staff in ‘A’ bungalow. It was said that the home’s policy requires 2 members of staff to administer medication, and that there are often not enough trained staff on duty in each of the bungalows. Therefore, the 3 bungalows are often interdependent. George Beal House DS0000033055.V289366.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): 22 and 23. Quality in this outcome area is good. The home has satisfactory systems in place to protect service users from harm and abuse, and to deal with any complaints or concerns about the service. EVIDENCE: Records, and information supplied by the home since the last inspection, indicate that there are satisfactory arrangements in place to deal with complaints about this service, and any potential POVA (Protection of Vulnerable Adults) incidents. During this inspection, it was discussed that two service users in one of the long stay bungalows did not get along. It was said that one of these individuals presented a risk to the other. To this end, it was observed how staff tried to support these individuals separately. One example of this was through two separate sittings at meal times. It was not clear if there were any plans to look into alternative accommodation in the long term, for one or both of these individuals, to promote better compatibility. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 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, 27 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment does not adequately meet the requirements of the National Minimum Standards for Younger Adults, and is institutional in a number of aspects. Despite the opportunity to create better access and facilities for service users, recent environmental improvements suggest that this has not actually happened. EVIDENCE: George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 18 As previously reported, a number of aspects regarding the organisation of the home and building were dated, and institutional. It is understood that the long-term plan for this service is re provision, but the timescale for this to take place was still not known at the time of this inspection. Since the last inspection, works to refurbish the bathrooms and kitchenettes in all three bungalows had begun. Despite some obvious improvements, it was discussed that the finished works would still not adequately meet the specific needs of some service users, or promote better access and choice. For example, it was discussed that one service user needed to use a moulded commode. However, a specially adapted toilet – to replace this, had not been included as part of the refurbishment. Also, due to a lack of space, it was said that service users in ‘B’ bungalow, would only have the choice of a shower (on a shower trolley), and the new bath in ‘C’ bungalow was already raising health and safety issues for staff. Furthermore, some of the new kitchenettes had been poorly fitted, and none provided any more access for service users, or equipment to allow service users to participate in preparing food within their own living bungalows. It was also noted that the décor in ‘A’ bungalow needed some attention, and cracks were visible in the living room walls. The manager provided a response regarding the building issues after the inspection. She stated that she planned to meet with the responsible individual for this service, Kate Walker, to discuss the problems that have arisen. It was said that the home had also made a formal complaint on behalf of the service users, regarding problems with the whole refurbishment process. The environment was noted to be clean, tidy and free from offensive odours during this inspection. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 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 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team are committed to providing a quality service to the service users however; this is also dependent on there being sufficient numbers of staff on duty. To this end, there may be times when only the basic needs of service users can be met. EVIDENCE: On the afternoon/evening of this inspection, there were two members of staff supporting four service users within ‘A’ bungalow. One member of staff had worked at the home for a number of years, and the other member of staff was an agency member of staff, who worked at the home on a regular basis. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 20 It was noted that staff had little quality time to spend with the service users. Although support was provided in an unhurried and relaxed manner, it was said that staff were often only able to meet service users’ basic needs, and that practices were sometimes institutional. One example was the fact that the night staff come on duty at 9pm, and at this point, the majority of service users need to be ready for bed. It was discussed that there are only two waking night staff, and one sleeping in member of staff per night, to monitor the three bungalows. See also ‘individual needs and choices’, and ‘personal and healthcare’ sections of this report. It was discussed that the home’s routines should be arranged around the preferences and needs of the service users. It was previously reported that staff vetting records were being held centrally and not in the home as required. By the time of writing, the inspector had been told verbally that the responsible individual for this service, Kate Walker, had begun the process of setting up a more flexible agreement with the CSCI, about the storage and inspection of staff vetting records. A staff training and development plan was not in place. The manager said that this was still in the process of being developed. It was discussed that there had been significant gaps in the provision of staff supervision, although this was starting to improve. The manager and resource manager stated that previous issues regarding staffing shortages were being addressed. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 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, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear line management structure in place, and there is evidence to suggest that managers are committed to making improvements for the service users at George Beal House. EVIDENCE: George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 22 Since the last inspection, the manager, Violet Masters, had successfully completed the CSCI registration process. Mrs Masters holds an ‘NVQ 4 in management’ certificate, and an operations manager confirmed prior to this inspection, that Mrs Masters would begin the required ‘NVQ 4 in Care’ in May 2006. Staff who were spoken to, spoke positively about each other, and the management of the home. However, some felt that access to management could be improved. Once again, it was observed that the team worked well together, and as a result, a relaxed and friendly atmosphere was noted. No reports as required by regulation 26 of the Care Homes Regulations 2001, had been received by the Commission in respect of this home, since the last inspection. Despite this, other communication from the home’s management has been received by the CSCI on a regular basis. In a recent meeting with the responsible individual for this service, it was discussed that a new monitoring system will be introduced across the service. It is proposed that in the future, resource managers will carry out monthly visits to each service, whilst the operations managers (also the responsible individuals), will continue to carry out their own visits, approximately every 3 months. The manager confirmed that a quality monitoring system for the home was in the process of being developed. The resource manager provided evidence that staff had electronic access to organisational policies and procedures, including a majority of those set out in Appendix 2 of the National Minimum Standards for Younger Adults (18-65). These were not verified on this occasion. No concerns relating to health and safety were noted during this inspection. George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 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 3 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 1 2 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 X 15 2 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 1 X 3 3 X George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 24 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 YA39 Regulation 24 Requirement Ensure that an effective quality assurance programme is developed. (Previous timescale of 31.5.05 not met). Ensure that service users are actively supported to help plan, prepare and serve meals in the home. (Previous timescales of 31.5.04 and 30.6.05 not met). Timescale for action 28/02/06 2. YA17 16 28/06/06 3. YA6 15 Ensure that care plans are 31/01/06 completed for all service users, which fully meet the requirements of NMS 6 for Younger Adults. This must include any restrictions on choice and freedom, and identify clear goals with regard to the individuals development of skills and abilities. (Previous timescales of 1.7.04 and 30.6.05 not fully met). Demonstrate that that satisfactory recruitment procedures (for all staff) have been followed. *Please note that from 26/7/04 31/01/06 4. YA34 19 George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 25 ‘Schedule 2’ has been updated within the amended Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. Also, from November 2005, new CSCI guidance is in place regarding the storage and retention of staff vetting records. Arrangements should now be made in line with this guidance. (Previous timescale of 30.4.05 not fully met). 5. YA26 16 Provide a telephone point (in service users bedrooms) or access to a cordless phone handset for use in rooms. (Previous timescales of 30.10.04 and 30.6.05 not met). 31/12/05 6. YA35 18 31/01/06 Introduce a training and development plan for all staff that incorporates induction, LDAF, mandatory, specialist and NVQ training. The plan must also identify how 50 of the care staff will hold an NVQ award in care by 2005. (Previous timescale of 31.5.05 not fully met). Service users must be offered a varied choice of meals, which meet their dietary and cultural needs. (Previous timescale of 15.5.05 not met). Individual risks and hazards must be assessed prior to admission for all service users. Risk management strategies must then be agreed, recorded, and reviewed on a regular basis. All service users must have the DS0000033055.V289366.R01.S.doc 7. YA17 12 and 16 15/01/06 8. YA9 13 31/01/06 9. YA13 12 and 16 15/01/06 Page 26 George Beal House Version 5.1 opportunity to access the local community, and to engage in appropriate activities both in and out of the home. 10. YA19 12 and 13 With regard to pressure care, service users must be assessed by a person trained to do so, to identify those individuals who are at risk of developing pressure sores, and appropriate intervention must then be recorded in each person’s care plan. Not assessed on this occasion. Visits as specified by Regulation 26 of the Care Homes Regulations 2001, must be carried out on a monthly basis. Copies of the reports must then be forwarded to the CSCI. Service users must be enabled as far as practicable, to make decisions with respect to the support they receive, and any arrangements that directly affect them. The home’s policy and practices regarding the storage, administration, and disposal of medication, must include all elements as set out in NMS 20 for YA (18-65). 31/12/05 11. YA39 24 31/01/06 12. YA7 12 30/04/06 13. YA20 13 19/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 George Beal House DS0000033055.V289366.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!