Care Home: Beach House

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• Clover House
• Parkside
• Park Lodge
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• St Bonaventures
• Hudson Road
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What the care home does well People living at Beach House were being involved with different activities and were getting out into the community, they were being supported to gain new skills and be more independent. On comment made was “I like shopping and going to pub in the evenings to play pool” Help with personal needs was being given with care and people were being treated with respect. People living at Beach House were being given support to stay in touch with families and friends. People were being involved in making decisions about how they spend their time. They said they could do what they wanted.Beach HouseDS0000061294.V377802.R02.S.docVersion 5.3The staff team worked well with the people living in the home, they were described as “Brilliant” and “Helpful” Everyone said they liked the food at the home, they were able to choose meals to be included on the menu and they helped with shopping and cooking. What has improved since the last inspection? The homes guide had been updated by the people living at Beach House and staff, to provide more useful and interesting information. When promoting independence, more consideration had been given risk taking to help make sure people are as safe as possible. People were being supported to do more things for themselves and had been getting out and about more. To help ensure managers and staff do the right thing to make sure people are properly protected, the instructions for dealing abuse matters and reporting bad practice had been improved. Some parts of the home had been improved, including the kitchen and some flooring. What the care home could do better: The inspection visit showed the management of the home needed improvement; to make sure the home is run in the best interest of the residents. To ensure staff know exactly what to do for each person, individual care plans still needed to include details of all needs and goals and how they are to be met. To make sure people are properly and safely supported with their medication, medication practices, instructions, records and storage needed a number of improvements. Where people manage their own medication, this needed to be carefully considered with them, to help ensure they safely supported. To make sure all medication matters stay safe and proper; they should be regularly checked. Action needed to be taken to ensure people are safe and not put at risk, when travelling in the homes’ car.Beach HouseDS0000061294.V377802.R02.S.docVersion 5.3Some staffing arrangements needed to improve to make sure people get good support. To make sure people living at Beach House have a nice, comfortable place to live, a number of improvements were needed at the home. To promote the well being and safety of people at Beach House, improvements were needed to identify and reduce potential risks and hazards in the home. Key inspection report CARE HOME ADULTS 18-65 Beach House 322 Padiham Road Burnley Lancashire BB12 6ST Lead Inspector Mr Jeff Pearson Key Unannounced Inspection 1st October 2009 09:20 Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Beach House Address 322 Padiham Road Burnley Lancashire BB12 6ST 01282 429657 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) Mr Alfonce Zindoga Mrs Concillia Tambudzai Zindoga Mrs Concillia Tambudzai Zindoga Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 Date of last inspection 6th August 2008 Brief Description of the Service: Beach House is a large garden fronted terraced house, situated within a short walking distance to Burnley Town centre, the property is in keeping with the neighbourhood. The accommodation available is homely and domestic in style. There is a lounge, lounge/dining room, house bathroom, kitchen and laundry room. The home accommodates six people in four single and one double bedroom. Most of the bedrooms have en suite facilities. Mr and Mrs Zindoga own the home and Mrs Zindoga is the registered manager. Staff are on duty to provide support 24 hours per day. Weekly charges for personal care and accommodation range between £465 and £677.50 depending on the level of support required. Residents are responsible for additional extras such as hairdressing, toiletries, some activities and transport. Written information about Beach House, including the service users’ guide, statement of purpose and last inspection reports were available in the home. This information should help people make an informed choice about moving into Beach House. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 5 Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people using this service experience adequate quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at Beach House on the 1s October 2009. The visit took 8 hours and was carried out by one inspector. At the time of the inspection visit, there were 4 people accommodated at the home. The people living at the home and staff were invited to complete surveys, to tell the Commission what they think about the care service provided at Beach House; we received 3 completed surveys from people using the service, none from staff. Before the site visit, the registered manager/owner 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 at the home. The files/records of three people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with people using the service; with the registered manager/owner, and staff on duty. Various documents, including policies, procedures and records were looked at. Most parts of the home and some outside areas were viewed. What the service does well: People living at Beach House were being involved with different activities and were getting out into the community, they were being supported to gain new skills and be more independent. On comment made was “I like shopping and going to pub in the evenings to play pool” Help with personal needs was being given with care and people were being treated with respect. People living at Beach House were being given support to stay in touch with families and friends. People were being involved in making decisions about how they spend their time. They said they could do what they wanted. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 7 The staff team worked well with the people living in the home, they were described as “Brilliant” and “Helpful” Everyone said they liked the food at the home, they were able to choose meals to be included on the menu and they helped with shopping and cooking. What has improved since the last inspection? What they could do better: The inspection visit showed the management of the home needed improvement; to make sure the home is run in the best interest of the residents. To ensure staff know exactly what to do for each person, individual care plans still needed to include details of all needs and goals and how they are to be met. To make sure people are properly and safely supported with their medication, medication practices, instructions, records and storage needed a number of improvements. Where people manage their own medication, this needed to be carefully considered with them, to help ensure they safely supported. To make sure all medication matters stay safe and proper; they should be regularly checked. Action needed to be taken to ensure people are safe and not put at risk, when travelling in the homes’ car. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 8 Some staffing arrangements needed to improve to make sure people get good support. To make sure people living at Beach House have a nice, comfortable place to live, a number of improvements were needed at the home. To promote the well being and safety of people at Beach House, improvements were needed to identify and reduce potential risks and hazards in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 9 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 Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems and practices were in place to find out about peoples’ individual needs, abilities and choices, before they move into the home. EVIDENCE: Since the last inspection the guide to the home had been revised and updated with the involvement of residents and staff. This was readily available in the home and provided some useful information, including the aims of the service also, details about transport, meals and social activities. It was written from the residents’ viewpoint, therefore had headings such as ‘our house’, ‘our staff’, and ‘when we are not happy’. Some pictures had been included, to help make it more interesting and easier to understand. The residents spoken with confirmed they had helped put the guide together. The manager said there had not been any new permanent or short stay admissions to the home since the last inspection. The AQAA (Annual Quality Assurance Assessment) completed by the manager indicated that good systems were in place to find out about peoples’, needs abilities and interests Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 11 before moving in to the home, also that when a placement is being considered, the home makes sure that everyone, both residents and staff feel that the person is suitable for Beach House and that they will fit in. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning at Beach House did not always ensure peoples’ individual needs and choices were known and planned for. EVIDENCE: Since the last inspection some progress had been made with the residents individual care plans. It was apparent efforts were being made to introduce a more person centred approach. The manager said some staff and residents had attended training in person centred care planning. Residents had been supported to complete an ‘all about me’ book which they kept in their rooms; this included their favourite things, photographs, school and work life and family background. They were sensitively written from the person’s perspective, with terms such as “Things that help me have a good day” - “How Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 13 I like to be supported”- “Things that don’t help my day go well”-“Whats important to me”. There were also individual care plans for each person which included some useful information about people’s individual needs and lifestyles. However, some of the care plans seen had been drawn up 3 years ago and although records were kept of reviews, the plans had not been properly updated, to reflect changing needs and goal planning. Some of the details were brief and did not always provide staff with clear instructions on how to provide support, for example in response to behavioural needs. The manager said they were continuously trying to produce a format which works best for service users and staff. People living at Beach House were being involved in activities of daily living; for example, they answered the door and telephone. They were being asked about day to day matters such as trips out to the shops, meals and activities. Residents meetings were meetings being held; to discuss menus, social activities, holidays and other matters, “We chose to go to Scarborough for our holidays”, explained one person. Information in care records showed the residents had been involved in agreeing decisions, for example about bed times and managing their medication. Residents completing surveys indicated they made decisions about what they did each day. Information about advocacy service was available at the home. The residents were being more actively involved with recruiting staff. Discussion with residents and staff and observation of support practices, showed people were being enabled to take risks to support independent living and skill development. Progress had been made in considering specific risks; a risk assessment questionnaire had been completed with some residents to help make sure they had an awareness of promoting their personal safety. Records seen, showed risk assessments had been carried out in relation to behavioural matters. However, instructions for staff on recognising and responding to risks were not detailed and specific enough, to promote effective person centred support. It was not clear that the risk assessments had been properly reviewed, for example, one assessment seen was dated 2007 and not been updated since. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 14 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): This is what people staying in this care home experience: 12,13,15,16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Beach House were being supported to develop their skills, engage in activities and use community resources. EVIDENCE: This inspection showed people at Beach House were being supported to further develop their independence skills, by doing more things for themselves and by pursuing new experiences. The residents spoken with indicated they were happy living at Beach House, they talked about the various individual and group activities they were involved with, including, exercise classes, card making, luncheon clubs, gardening, football, shopping, going to the pub, computer and college courses. We are getting out more often, explained one Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 15 person. All said they had enjoyed their holiday in Scarborough and had put together a large framed photo display of their time away. Completing the ‘all about me’ books with staff had helped the residents to further consider their life and aspirations. Activity programmes had been devised; to provide some structure to supporting chosen activities. The AQAA (Annual Quality Assurance Assessment) showed further improvements were to be made with planning activities and events, including trips out and activities in the home. Independence was being encouraged; people had some responsibilities for domestic chores as part of skill development, such as, cleaning their rooms, doing laundry and cooking. One person had a job delivering newspapers. Daily routines in the home were flexible and influence by peoples’ planned activities and lifestyles. People could spend time in their own rooms whenever they wished, they had keys to their bedroom doors and staff respected their privacy. Records and discussion showed people’s relationship needs were being considered; people were being supported to keep in touch with families and friends as appropriate. Visitors were being made welcome at the home. The residents spoken with were again happy with the variety and quality of the meals. Some helped with the shopping all prepared their own, lunches, suppers, drinks and snacks, they took turns to prepare the main meal, “we can make what we want”, explained one person. Menus were being agreed and discussed during residents meetings; peoples’ favourite meals had been included, one person said “They ask us what we want then they put it on the menu”. Information about healthy eating was available and this was being encouraged. Staff spoken with indicated the food budget was satisfactory, the fridge and freezer were seen to be well stocked with various types of products. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Medication practices were not always effective in ensuring people are safely and properly supported. EVIDENCE: People living at Beach House needed minimal support with personal care needs, where needed guidance an support regarding personal hygiene was being given and was included in care plans. It was apparent from observation and discussion they were being supported to choose their own clothing and take an interest in their appearance, one person explained they had visited the local hairdressers. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 17 Records and discussion showed people were getting help with healthcare when needed, for example arrangements had been made for health care appointments and check ups with opticians and dentists. Health action plans had been devised in consultation with the learning disability nurse team. Systems were in place to monitor peoples’ general health and wellbeing. Medication storage facilities were satisfactory, clean and secure. Medication policies and procedures were seen to be available. A signature list was now being kept to identify staff entries on the records. There were some good individual instructions on ‘when necessary’ items. The manager said all staff had undertaken medication management training with contracted pharmacy, it was advised a competence based assessment to be carried out, to show they had attained the necessary practical skills. The manager said regular audits were being carried of systems and practices, however, this inspection showed there were several matters needing attention to ensure people are properly and safely supported with their medication. Some prescribed items were not being offered as per the instructions on the label, for example pain killers were being offered or requested ‘when necessary’. Some items were no longer in use and therefore should not have remained entered on the MAR (medication administration record). It was said one item was currently being refused but this had not been recorded as such on MAR chart. Some entries on the MAR chart were unclear as they did not correspond with the specified ‘key code’. There were several handwritten entries of prescribed instructions on the MAR chart, however, they had not been signed by the person making the entry, or confirmed as correct by another person. Care records included individual agreements with people about medication administration, but it was not clear that where people were managing their own medication, that this had been carefully considered. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service had not been sufficiently protected from potential harm or injury. EVIDENCE: People living at Beach House said they were aware of how to make a complaint, they felt the regular residents meetings were good for discussing any issues, “I would speak to staff if I was not a happy”, said one person. The complaints procedure was displayed in the home and had been updated to include current contact details of the Commission. The procedure was written in plain language and included pictures to help explain the process. The manager said there had not been any complaints made at the home within the last 12 months and none had been received at the Commission. Since the last inspection visit, the homes policies and procedures in relation to safeguarding people had been revised and updated, to include more appropriate guidance. Progress had been made on ensuring there are clear step by step procedures on making safeguarding alerts. The Whistle Blowing (reporting bad practice) procedure had also been revised to include specific referral details of the Commission or Social Services. Records of meetings showed staff had been informed of revised protection policies and procedures. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 19 During the course of the inspection, we were made aware of specific practices which gave us cause for concern. We considered people had been supported to take unnecessary and unacceptable risks, due to defective car safety equipment. It was therefore necessary for us to make a safeguarding alert to Social Services. At the time of writing this report this matter was being pursued. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Beach house offers some comfortable accommodation, but some facilities and furnishings did not promote the well being and safety of the residents. EVIDENCE: Some improvements had been made to the accommodation for the people living at Beach House, for example, new laminate flooring had been fitted in the lounge/dining room and the hallway, new cupboards and work tops had been provided in the kitchen. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 21 People spoken with were not all entirely satisfied with their bedrooms. One had been decorated and the occupant had chosen the colour scheme some new furniture had been provided, however, the wallpaper in this room was seen to be hanging off in one corner suggesting there may be a problem with damp, also the door to the bedroom did not fit into the doorframe properly. Another bedroom had some new furniture provided, but the covering on the bed base was seen to be in a poor state, it was worn and torn, exposing the bed frame beneath. The curtain rail at the window was seen to be hanging down. In one en-suite bathroom, the water temperature at the washbasin was found to be excessive and the boxed in area around the radiator had fallen off, presenting as unsightly potentially hazardous. We were made aware of a potential tripping hazard on the floor between the kitchen and dining room. We were told some mattresses and pillows were worn and in need of replacement, that the owners leave things too long before they replace things. Although an action plan had been devised to make improvements at the home, we considered progress was to slow and not sufficient in ensuring people are provided with a satisfactory standard of accommodation. Audit and maintenance checks were being carried out but we found there was not always a timely response to the matters arising. The general layout of the home, in particular the suitability of the basement bedrooms was discussed with the manager. It was advised these matters be identified as areas for further development, in the homes longer term plans. The home was found to be mostly clean and free from unpleasant odours, however, it was noted some bedrooms were quite dusty, the manager agreed to address this matter. Satisfactory laundry equipment and facilities were available. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 35 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing arrangements provided people at Beach House with satisfactory support. EVIDENCE: Positive interactions were observed between the residents and staff. People spoken with were appreciative of the support provided by the staff team; they described the staff as fantastic, wonderful and okay. “I like the staff here they are very nice and good too” was one comment made. The staff rota showed generally satisfactory staffing levels were in place. Some progress had been made with planning for effective support in response the residents’ needs and lifestyles, however, staff spoken with again said they were not always sure when the manager would be on duty to cover shifts. At Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 23 the time of the inspection the deputy manager was on holiday, it was apparent her shifts had not been properly covered; the manager said she was working some additional hours and additional staff were in the process of being recruited, however, better arrangements were needed to ensure people receive effective consistent support. There had no been any new staff recruited since last inspection, therefore staff recruitment practices and induction training were not evaluated. All the staff had NVQ (National Vocational Qualifications) in promoting independence, level 2 in health and social care. The deputy manager had completed NVQ level 4. Staff records were seen showing training completed, ongoing and arranged training in, Fire Safety, Food Hygiene and Protection Of Vulnerable Adults training. The manager had also provided some in house training in relation to mental health issues, she was aware of the expectations in ensuring all individual staff are suitably trained and that training updates are to be ongoing, however, It was not clear all staff had been given specific training in relation to supporting people with a learning disability. Discussion and records showed staff were receiving individual one to one supervisions. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration practices were not always effective in ensuring the home is run for the benefit and well being of people using the service. EVIDENCE: During our previous inspection we had some concerns about the management practices at the home; we therefore recommended that management arrangements be given attention, to ensure Beach House is effectively run for Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 25 the benefit of people using the service. The Commission has since been advised by letter that there were to be changes in the management arrangements at the home, that Mrs Zindoga was proposing to relinquish her position as registered manager and that the deputy manager would be applying for this position. Mrs Zindoga also indicated that the deputy manager was currently running the home for experience, supervised by herself. However, this inspection showed some progress had been made to provide better outcomes for people living at Beach House, in particular promoting independence, but some matters again had not been sufficiently addressed and there were further management practices in need of attention. Within our previous inspection report we offered advice on effectively using the AQAA (Annual Quality Assurance Survey) for development planning at the home. However, we found the AQAA did not properly show how the improvements identified at our last inspection had been addressed, nor did it provide an accurate refection of the shortfalls we found at the home on this visit. We were therefore unable to fully rely upon the content of this document as a credible source of evaluation of the service and future development. Although the residents were being consulted during meetings and as part of the care planning process, there had not been there had not been any recent formal consultation surveys with the people living at Beach House, relatives, staff or Social Workers. The homes AQAA indicated the servicing and checking of equipment and installations, some records were seen in support of this, such as electrical appliance and gas safety testing However, it was noted the homes electrical wiring certificate was two years out of date and therefore in need of immediate attention, the manager gave assurances this matter would be addressed. A report seen, showed the need to provide an up to date electrical wiring certificate had previously been highlighted by a visiting Fire Safety Officer, who had also identified further matters requiring attention, the manager said these had been addressed, however, it was noted there were some gaps under the door between the dining room and hallway, which presented as a potential risk to fire safety. We also found several matters which had potential to be a risk to health and well being of the residents (as previously highlighted within this report). Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 26 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 1 ENVIRONMENT Standard No Score 24 2 25 2 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 x 2 X X 1 X Version 5.3 Page 27 Beach House DS0000061294.V377802.R02.S.doc NO 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 YA20 Regulation 13(2) Requirement Where people self-administer medication written risk assessments must be completed and kept under review, to help ensure people always receive any help they may need to administer their medicines safely. Effective arrangements must be put in place to ensure that all medication is safely administered to service users in accordance with the prescribers directions. This is to help protect the safety and wellbeing of people using the service. Effective arrangements must be made, to prevent people using the service from being placed at risk of harm when travelling in the homes’ car. This is to protect their safety and wellbeing. Effective arrangements must be made to ensure the home is kept in a good state of repair externally and internally. This will promote the well being and safety of people using the service. Effective arrangements must be DS0000061294.V377802.R02.S.doc Timescale for action 27/11/09 2. YA20 13 27/11/09 3. YA23 13(4)(6) 20/11/09 4. YA24 23(2)(b) 31/12/09 5. YA42 23(4) 27/11/09 Page 28 Beach House Version 5.3 6. YA42 13 (4) made to ensure the home has adequate precautions against the risk of fire. This will promote the well being and safety of people using the service. Effective arrangements must be 27/11/09 made to identify and reduce potential risks and hazards in the home. This will promote the well being and safety of people using the service. 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 YA6 Good Practice Recommendations To ensure all people using the service receive appropriate person centred support, individual care plans need to provide up to date detailed information and instructions for staff to follow and are to be used as working documents. Instructions for staff on recognising and responding to risks should be more not detailed and specific, to promote effective person centred support. Arrangements should be made to show risk assessments are being properly reviewed and updated. To ensure management of medication is safe and appropriate, the auditing system should include a more thorough check of all aspects, including records, storage and administration. Arrangements need to be made to ensure people using the service are provided with suitable beds and bedding. To promote continuity, stability and the planning of service users activities, action should be taken to ensure the staff rota is consistently adhered to. Action should be taken to ensure the staff development programme includes training in relation to supporting people with a learning disability. The homes management arrangements need attention, to ensure Beach House is effectively run for the benefit of people using the service. Quality assurance systems should include more formal consultation with people using the service and other DS0000061294.V377802.R02.S.doc Version 5.3 Page 29 2. YA9 3. YA20 4. 5. 6. 7. 8. YA24 YA33 YA35 YA37 YA39 Beach House 9. YA42 relevant people. To promote the health safety of people using the service and staff, action should be taken to ensure that training in all safe working practices is ongoing. Beach House DS0000061294.V377802.R02.S.doc Version 5.3 Page 30 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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