Inspection on 08/09/05 for The Bay

This inspection was carried out on 8th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Bay 06/11/08

The Bay 15/05/07

The Bay 02/05/06

The Bay 03/05/05

The Bay 02/12/04

The Bay 22/06/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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Dovedale Court

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Bay 29 Dymchurch Road St Marys Bay Kent TN29 0HF Lead Inspector Wendy Mills Announced 8 September 2005 9:30 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 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 Stationary 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. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Bay Address 29 Dymchurch Road, St Marys Bay, Kent, TN29 0HF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care home only 16 Parkcare Homes (No. 2) Limited Category(ies) of Learning Disability x 16 registration, with number of places The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are special conditions to allow for three residents with a learning disability to also have an associated physical disability. Date of last inspection 3rd May 2005 Brief Description of the Service: The Bay is a home for up to sixteen people with a learning disability. It is situated in a small close just off the main Dymchurch road at St Marys Bay. The accommodation is provided in three familiy-sized, modern, detached houses that are linked by a communual back garden. Prior to 2005 these houses were registered as three separate homes. The decision to register The Bay as one home was made in April 2005. The Bay is situated close to sea and local shops. Larger shopping areas, educational and leisure facilities are available in the nearby towns of Ashford, Hythe and Folkestone. The manager for home is Ms Janey Beaney. Her application for registration is currently being processed by the Commission for Social Care Inspection (CSCI). The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection began at 9.30am and lasted eight and a half hours. Mrs Felicity Elvidge, Adult Protection Co-ordinator, joined the inspection at 2.30pm. During the course of the inspection spoke to ten of the residents, some in the privacy of their own rooms. The inspector also spoke to three members of staff in private and held discussions with the manager, Ms Janey Beaney, and the area manager for the Craegmoor group, Mrs Sarah O’Mara. A tour of the home was undertaken in the company of Mrs Elvidge and one of the team leaders. Documentation, including all care plans, was examined and both indirect and direct observation was used throughout the inspection. The residents, staff, manager and area manager are thanked for their assistance during this inspection. What the service does well: What has improved since the last inspection? There have been further improvements to the environment and a new path has been laid to the back gardens. This has greatly improved the safety of access for the residents and staff to the communual garden area. The garden of one house has been tidied and there are further plans to plant shrubs and flowers to make it more attractive. Some more new furniture has been purchased for the communual areas and for one vacant room. The service user guide and the complaints procedure have been reviewed and revised. These documents have used pictorial descriptions to make them easier to understand. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 6 There has been progress in staff absence management and there is now better monitoring of staff sickness rates. A number of enthusiastic new staff have been appointed. Unfortunately, during the inspection some gaps in basic training, for example, lack of food hygiene training, were identified. Support and supervision for the manager of the home has recently been provided directly by the area manager. Since this inspection was made the Company has informed the CSCI that they have asked Mr Keith Yarnley, a registered manager from another home within the Company, to take over the management of The Bay. What they could do better: The management of the company could improve communications with all staff. In particular, they should speak to staff, in private and in confidence, during their monthly visits to the home. Staffing levels at the home remain an area for serious concern. The home is in the process of reviewing the needs of the residents against staffing levels, following concerns expressed at the last inspection. It is good to note that, at the end of this inspection, the area manager agreed to put an additional member of staff on in the home for each shift. The home must complete its review of staffing needs as a matter of urgency and ensure that staffing levels meet the needs of the residents. Progress has been made in respect of the environment but a number of significant health and safety hazards were noted on the day of inspection. The company and the home must review the health and safety polices and procedures, staff training and the way in which the registered persons carry out the monthly Regulation 26 visits in order to ensure that the health and safety of the residents is protected at all times. The home must improve its basic training for new staff. Since the last inspection there have been several changes in staff personnel, and there are several new staff in the home. This inspection identified gaps in their basic training, for example, two new members of staff were unaware of kitchen hygiene and safety requirements, and one had no understanding of the danger presented by a COSHH cupboard with a broken lock. Although some staff say that improvements have been made to the way the home manages medicines, they still perceive that the home is not stringent enough in its procedures for the administration of medicines. The home must review its procedures to ensure they are safe. The home should take more care with its admissions procedures. During this inspection it was found that a new resident had been admitted to the home soon after an adult protection alert had been raised and only a week before an The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 7 Adult Protection meeting was scheduled. No extra staff had been scheduled to support the admission despite concerns raised at the previous inspection about staffing levels and that the new service user had some very specific identified needs. No evidence was found that the existing residents and their supporters had been consulted. 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 Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 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 standard(s) 1,2,3&4 The statement of purpose and the service user guide contain appropriate information, however, the home is poor at communicating it’s aims and objectives to the residents and their supporters. There are sound written admissions policies and procedures but the home has not been diligent enough in putting the admissions procedures in action. This has resulted in the residents being put at risk EVIDENCE: The manager has worked to improve the service user guide and the complaints procedure. These are now in a simplified format that uses symbols and well as plain English. This is recent work and is not yet complete. The new format now needs to be communicated well to staff, the residents and their supporters. All care plans were examined and, in particular, those of the most recently admitted residents. One resident appears to have been admitted without staff being clear about his care needs. No additional staff were scheduled in order to support this resident despite there being clear and significant care needs. Staff to whom the inspector spoke were clearly stressed by the additional work the admission had entailed and there were contradicting opinions amongst staff as to how needs should be met. No evidence was found to suggest that The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 10 the existing service users and their supporters had been consulted prior to this admission. The home must take more care with future admissions to ensure that the other residents are consulted and that adequate staffing levels and staff training are in place before admission. The area manager of the Company agreed to place an additional member of staff on each shift at the end of this inspection, when these serious concerns were pointed out. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8&9 Whilst the home has worked hard to ensure that documentation about the care needs of the residents is both up-to-date and appropriate, it has not communicated well with the residents, their supporters and staff, to ensure that the written plans are carried out. This has led to confusion about care and some unhappiness amongst the residents. More seriously, it has led to a number of Adult Protection alerts being raised. EVIDENCE: The manager has worked hard to update the care plans and to ensure that appropriate written risk assessments are in place. Unfortunately, some residents and their care managers did not appear to be aware of the changes in their care plans. Several care managers said that the home had not communicated changing needs to them. All the care plans were examined. It was found that although care needs had been identified, staff were largely unaware of these. There were conflicting opinions as to how to meet needs. For example, several staff were using different ways of managing challenging behaviour and incontinence. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 12 Documentation showed that, whilst in some instances, professional help had been sought on behalf of the residents, there were gaps in accessing the appropriate health care professionals. For example, one resident is not registered with a dentist and another lacks psychological support. The home must make every effort to communicate the care needs of the residents and ensure that staff are aware as to how to meet these needs. The home must also ensure that staff have adequate training in order to meet these needs. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,14,15,16&17 There continues to be an improvement in the opportunities the residents have for their personal development but there still needs to be more consistency. Whilst the home generally does well in supporting the residents to maintain contact with friends and family, it needs to be more aware of specific needs in respect of sexualised behaviour. Whilst there is a good supply of fresh produce in the home and residents mostly enjoy their meals, food hygiene in the home needs to improve. EVIDENCE: Care plans and activity schedules show that the residents have a good variety of planned leisure and cultural activities. The manager is commended for the way in which she has sought out further opportunities for the residents. Person Centred care is now being introduced into the home and there are plans in place to better support the residents in carrying out their household tasks. However, staffing levels remain low and staff are expected to ensure that the houses are clean and meals are prepared as well as supporting the residents in The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 14 their activities. This leaves very little time either to support the residents in carrying out household chores or to involve them in creative activities within the home. On the day of inspection it was observed that one resident was colouring in a child’s colouring book. This activity was raised as a point of concern at the last inspection. It was. therefore, disappointing to find that this activity is still continuing. The home should find more creative and age-appropriate activities for the residents who spend a lot of time at home. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19& 20 Whilst care plans indicate the personal support needs of the residents, more effort is needed in communicating these needs to the staff to ensure consistency and the protection of privacy and dignity. The home needs to do more to ensure that the physical and emotional needs of the residents are met. Whilst some progress has been made to improve the way in which medicines are managed within the home, more attention to detail is required. EVIDENCE: Indirect observation and conversation with staff indicated that there was little understanding amongst some staff, of the need to respect the privacy and dignity of the residents. For example, the bathroom door in one house did not close but no attempt had been made to repair this. The maintenance book was unavailable for inspection so it was not possible to confirm if this problem had been identified. If a bathroom door does not close then the residents will not be afforded any privacy and this shows a lack of respect for their dignity. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 16 Care plans showed that whilst most of the residents are registered with local GPs and dentists, there were some who were not registered with dentists. Some omissions in the recording of appointments and their outcomes was also noted. Feedback from health care professionals confirmed that there have been missed health care appointments. They also say that some staff who accompany residents to healthcare appointments have been poorly informed about the health needs of some residents and communication with the home has been poor. Some healthcare professionals express concern that the advice they give the home is not followed consistently. During the inspection one resident’s behaviour was not managed well by staff. There is a general lack of consistency in the way staff handle situations within the home. for example, in conversation with staff it was noted that there were at least three different approaches to managing challenging behaviour and two ways of managing incontinence. This lack of consistency is confusing for the residents and puts their health at risk. The home must communicate the health, social and care needs to staff in a clearer and more consistent way. Staff said that they have concerns about the way medicines are administered within the home. Some alleged that records are not always accurately made. For example, one alleged that a tablet had been lost but it was still recorded as having been administered. None of the current service users self-medicates. The policy and procedure guidance for the management of medicines in the home is extensive but not all is relevant to the Home; for example, the procedures include instructions for giving an injection without reference to the need for input from a healthcare professional. A review of medication policies, procedures and practice is required. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22&23 The home has improved the documentation in respect of complaints but there is room for improvement in the way it listens to staff who express concerns on behalf of the residents. Communication, staffing levels and staff training are poor. This has led to a significant number of Adult Protection Alerts being raised since the last inspection. EVIDENCE: The manager has worked hard to produce the service user guide and the complaints procedure in a simplified format. This will eventually make it easier for the residents and their supporters to understand how to make their concerns known. However, this now needs to be communicated well to the residents, their families and their supporters in order for it to be effective. The Company has a clear, written whistle-blowing policy, however, staff say that they do not feel they are heard when they raise concerns. Currently there are a significant number of Adult Protection Alerts open on residents at the home. Most of these are under investigation at present but two have already been upheld. The home must take action to ensure the residents are protected from harm at all times. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28&30 The environment of the home is generally clean and homely but neglect of basic health and safety and poor continence management within the home must be given a higher priority. The layout of the home and gardens is good. There is sufficient communual space whilst allowing for the residents to live in small, family-sized units. The bedrooms are nearly all of a very good size and can meet the needs of the residents. EVIDENCE: A tour of the home was undertaken in the company of Mrs Felicity Elvidge, Adult protection Co-ordinator and Mr Andy Levine, team leader. Several health and safety hazards were noted. The lock on the COSHH cupboard in one house was found to be broken and this lock appeared to have been forced. Broken furniture and electrical equipment was stored on the landing of one house and a broken armchair was found in the lounge of another. “Cook from Frozen” meat was found defrosting directly onto a worksurface and in close proximity to the electric kettle and toaster. Water was found on the base of the kettle where the electric contact is situated. The dishcloth in the sink was The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 19 unclean. The staff member, who was working in the kitchen, seemed unaware of the dangers. We were informed that he does not hold a food hygiene certificate although he was preparing the evening meal at the home. As mentioned in the section about personal healthcare and support, the bathroom door in one house did not close. The team leader appeared not to understand the significance of this, in that it compromises privacy and dignity, and blamed the behaviour of one resident for the defect. The maintenance book was unavailable for inspection so it was not possible to ascertain if this defect, and others, had been reported and put on the list for repair. It is a concern that the maintenance book was unavailable on the day of inspection. If this is generally the case then staff will find it difficult to report concerns that may affect the safety of the home. The accommodation at the home is provided in three separate houses that are linked by a pathway through the communual gardens at the rear of the property. This pathway has recently been re-laid. This has made a vast improvement to the access to, and appearance of, the gardens. The gardens have also been tidied and more planting is now planned. The three houses allow for groups of residents to live as small family-sized units whilst keeping in contact with their friends in the other houses. Internally, new furniture has been provided and the décor is of a good standard. Carpets and soft furnishings in the communual areas are bright and in very good condition. This provides the resident with a stimulating and pleasant environment. Most rooms are of a good size and reflect the interests and lives of the residents. Most rooms are well decorated and furnished, however, some bedrooms would now benefit from new carpets. New furniture has been purchased to place the broken bedroom furniture identified at the last inspection, however, the bed in this room, which is now empty, is in a poor state and should be replaced before any new resident is admitted to it. A chair in this room did not meet fire requirements. Due to the poor management of continence issues, one room now has an offensive odour. As this room is on the ground floor, adjacent to the kitchen, the unpleasant odours impact on all the other residents. The home must improve the way it manages this situation and ensure that it deals with the offensive odours. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34&35 There remains a high level of commitment by most of the staff, however, staffing levels still remain too low to meet the identified needs of the residents. Staff morale amongst some staff remains low. This causes tensions amongst the staff and has an adverse effect on the residents. There has been some improvement in staff supervision but communication within the home is still poor. EVIDENCE: There had been no improvement in staffing levels since the last inspection, despite the admission of a new resident with significant care needs. the home is in the process of re-assessing the care needs of all the residents following the concerns raise at the last inspection. However, this process is far from complete and no re-assessments were available at this inspection. It is good to note, that when the concerns from this inspection were pointed out to the manager and the area manager, the area manager agreed to put an additional staff member on each shift. The home is now beginning to deal with poor staff performance and sickness levels are now reducing. There is now a structure to allow for regular staff The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 21 supervision, however, staff said that they still do not feel that the management listens to their concerns. When asked if they met with the company representatives who carry out the monthly, Regulation 26 inspections, they said that although the company representatives always spoke to them in passing, they had never met with them in private nor were they asked for their views on the running of the home, during these visits. As identified previously in this report, communication appears to be poor, with staff not knowing the best ways to manage challenging behaviour, structured activities, privacy and dignity and health and safety issues. The home must continue its efforts to improve communication. As identified in the section on the environment, some staff lack training in key areas such as food hygiene, management of COSHH substances and privacy and dignity. Staff also lack training in specialist areas, such a diabetes and continence. The management must carry out a training needs analysis and ensure all staff are adequately trained. It must also review its induction procedures to ensure all new staff have the skills to carry out the tasks required of them. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,42&43 Whilst the Company continues to make an effort to address the problems identified in the last two inspection reports, progress has been slow and this has resulted in the residents being put at risk. The health, safety and welfare of the residents are not adequately promoted. The company is financially viable and the Company is committed to making improvements at the home EVIDENCE: Since the last inspection the CSCI has had assurances, from both the regional manager and area manager for the company, that they are committed to making improvements at the home. The area manager has now taken on the direct line management of the manager. The manager has a caring manner but had little experience as a deputy manager before being put in the position of running a comparatively large home with several known problems. She has The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 23 worked hard to make improvements but has sometimes found it difficult to communicate her aims and objectives to many of the staff. In addition she has had to deal with some long standing performance issues with staff and this has taken much of her time. There are health and safety concerns about the home and these have been identified in previous sections of this report. Although regulation 26 visits are made monthly and reports sent to the CSCI, it appears that they have missed many concerns about the home. Since the last inspection the regional manager, Mrs Mary Preston, has assured the CSCI that the Company is not restricting financial investment in the home. she has indicated a willingness to provide extra staff at the home if the reassessment process indicates that this is necessary. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 1 1 x Standard No 22 23 ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 1 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 1 3 x 1 Standard No 11 12 13 14 15 16 17 2 1 2 2 1 1 1 Standard No 31 32 33 34 35 36 Score 1 1 1 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Bay Score 1 1 2 x Standard No 37 38 39 40 41 42 43 Score 1 1 1 x x 1 2 H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard ,7, 8, 9, 11, 16,33 Regulation 18(1)(a) Requirement The home must ensure that adequate numbers of suitably qualified members of staff are on duty at all times in order to meet standards for personal care, leisure and educational activity and the health and safety requirments. A training needs analysis is now required. NB This requirement is carried forward from previous inspection. The home must review its policies and procedures for management and administration of medicines to ensure that errors are prevented. NB This requirement is carrid forward from the last inspection The home must ensure that the residents are protected from harm at all times. There must be adequate numbers of staff on duty at all times and all appropriate checks must be carried out on all staff. NB This requirement is carried forward from the last inspection. The home must ensure that a health and safety audit is carried out and that all health and safety Timescale for action 8th September 2005 2. 20 13(2) 8th september 2005 3. 23 19,20,22 8th september 2005 4. 39, 40 23 8th September 2005 Page 26 The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 5. 18 12(4)(a) 6. 3 14 7. 3 14 8. 6 12,13,15 9. 15 12,13,15 10. 17 16(2)(i) 11. 19 12;13 deficiencies are rectified. NB This requirement is carried forward from the last inspection. The home must ensure the privacy and dignity of the residents at all times. Staff to receive further training and better supervision. NB a recommendation for greater care in respect of privacy and dignity was made in the previous inspection report. This is now a requirement.. The home must follow its own written procedures before admitting new residents to home. The care plans for all prospective residents to home to be submitted to the CSCI prior to a place being offered. The home must ensure that all staff are aware of the care needs of all new residents and are clear about how these needs will be met. The home must ensure that the needs of all the residents are identified. It must communicate these needs and how they will be met to all staff. The home must give appropriate support in order to promote appropriate personal relationships. The home to tell CSCI in writing about how it is to manage sexualised behaviour.. The home must ensure that food is properly prepared. All staff must receive food hygiene training. Proof of staff training in food hygiene to be sent to CSCI. The home must ensure that the phyical and emotional needs of the residents are met. All residents to be registered with GPs and dentists. Home to communicate with care 30th September 2005 30th September 2005 30th september 2005 30th September 2005 31st October 2005 31st October 2005 30th November 2005 The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 27 12. 23 13(6); 26 13. 27 23 14. 30 23(2)(d) 15. 31,32,33, 35,26 18 16. 37, 38 10 17. 39 15, 16 18. 42 23; 26 managers about the health and emotional needs of the residents and complete re-assessment process.. The home must ensure that all staff are adequatley trained in order to prevent the residents being harmed or suffering abuse or being placed at risk of harm or abuse. Staff views to be sought, in private, during Regulation 26 visits The home must ensure that toilets and bathrooms offer adequate privacy. Bathroom door to be mended so that it can be closed and locked. The home must ensure that all areas are clean, hygienic and free from offensive odours. Particular alttention to be paid to bedroom and toilet and bathroom facilities The home must ensure that adeqauate numbers of appropriately trained and supervised staff are on duty at all times. The registered persons must make adequate provision to supervise and support the manager The home must ensure that it adequately consults with the residents to ensure their views are taken into account A health and safety audit to be carried out and a wriiten action plan describing the way the home will be made safe. 31st October 2005 9th september 2005 9th September 2005 8th September 2005 8th september 2005 30th september 2005 30th september 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 28 No. 1. Refer to Standard Good Practice Recommendations The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection 11th Floor, International House Dvoer Place Ashford, Kent TN23 1HU 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 The Bay H56-H05 S23319 The Bay V231078 080905 Stage 4.doc Version 1.40 Page 30 - 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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