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CARE HOME ADULTS 18-65 Benjamin House 41 Ormerod Road Burnley Lancashire BB11 2RU Lead Inspector Mr Jeff Pearson Unannounced Inspection 12th March 2009 09:30 Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Benjamin House Address 41 Ormerod Road Burnley Lancashire BB11 2RU 01282 835926 01282 414506 healycare@ntlworld.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Bridget Mary Healy Manager post vacant Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 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: Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of Service Users who can be accommodated is: 10 Date of last inspection 26th March 2008 Brief Description of the Service: Benjamin House is part of Healy Care, which consists of three terraced properties. An additional property is used an office facility. The properties are situated on the same road, in what is primarily a residential area. Benjamin House is close to the resources available in Burnley town centre. It is registered to accommodate 10 adults under the age of 65 with a mental illness. The accommodation available is homely and domestic in style. There is a lounge, a room for smoking and a dining kitchen with conservatory area. Bedrooms are single, eight have en-suite toilets. Two of the bedrooms are situated on the ground floor. Staff are on duty to provide support 24 hours per day. Transport is occasionally available to enable service users to visit relatives and for outings within the community. The home had a Statement of Purpose and Service User Guide providing information about the support and services available. Copies of these documents and the most recent inspection report, were available in the homes lounge; this information should help people make an informed choice about accepting placement at Benjamin House. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 5 At the time of the inspection visit the range of fees was between £476.04 and £1000.00 per week. Toiletries, hairdressing private chiropody was not included in the fees. There were voluntary optional charges for entertainment and transport. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people using this service experience good quality outcomes. An unannounced inspection, which included a visit to the service, was conducted at Benjamin House on 12/03/09. The visit took 7 hours. The Inspector was accompanied by an Expert by Experience who is a person, who because of their shared experience of using services, visits a service with an Inspector to help them get a picture of what it is like to live in or use the service. The Expert by Experience, looked and general support practices, relationships and parts of the accommodation. The views of the Expert by Experience and comments received during the visit have been included in the report. A random unannounced inspection had been carried out at the home on 24/09/08. Random inspections are short, targeted inspections which may focus on specific issues that have come up or check on improvements that should have been made. This random inspection had been carried out to look progress was to assess progress in addressing the previously made requirement and recommendations. The findings were some progress had been made, but a requirement was made in relation to staff recruitment and recommendations made about staffing and management. A report following this inspection will be made available on request from the Commission, to members of the public or other enquirers. The people living at the home and staff were invited to complete surveys, to tell the Commission what they think about the care and service provided at Benjamin House, some were received at the Commission. Before the visit, the 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 two 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 living at the home, the acting manager and staff. Various documents, including policies, procedures and records were looked at. Parts of the home were viewed. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? To make sure the home is as safe as possible, arrangements had been made to review the fire safety precautions. To make sure the service can provide the right support, the way in which new people’s needs are considered and planned for had been improved. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 8 To make sure people receive proper care and support, action had been taken make sure care plans provide clearer details and instructions for staff, about any diagnosed mental illness. Care plans were being written in a style more easily understood by people using the service. Better records were being kept of people getting their medication, to show they are being properly and safely supported. What they could do better: This home must show ongoing improvement and good practice, to ensure there are continued good outcomes for people using the service. To do this, management of Benjamin House must continue to be effective. A manager needs to be registered with the Commission, to take legal responsibility for the day-to-day running of the home. To ensure people are well supported, staffing matters including, recruitment, training, and ensuring enough staff are on duty, needs to keep being properly managed. To show the home is being properly monitored, reports following unannounced inspection visits by the owner must be available in the home. To make sure the home keeps improving, there should be written guidance on measuring quality for the benefit of people using the service. To provide a more pleasant environment for the occupant, one bedroom still needs to decorated and upgraded. To show the home is being kept safe, servicing records should be readily available. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The admission process helped ensure peoples’ needs; abilities and choices were known and planned, for before they moved into the home. EVIDENCE: There was an indication within surveys, that people living at Benjamin House had been involved in choosing the home. Also, that they had received enough information about the home, to help them in their decision to move in. At the time of the inspection, action was being taken to produce a DVD version of the homes’ guide. Records and discussion showed that systems and practices were in place for managing both planned and emergency admissions. The acting manager explained the homes planned admission process; this involved gathering information from relevant professionals such as care coordinators and carrying out an assessment of the persons’ individual needs and abilities. New people being enabled to visit the home, to see the accommodation, join in an activity and meet with current residents and staff. Their compatibility to get along with the other residents would be considered at Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 12 this time. The acting manager had recently introduced a checklist, to assist with the admission process and was devising an evaluation survey to be completed with the person following their admission. Discussion took place about an emergency admission, which appeared to have been managed appropriately; action had been taken gather information, respond to identified needs and complete risk assessments. A more detailed support plan had then been drawn up and agreed with the person concerned. The AQAA (Annual Quality assurance Assessment) showed, that supporting more staff to receive specialist training for example, on Approaches to Mental Health, as a plan for future improvement at the home. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care planning process helped ensure peoples’ individual needs, abilities and choices were known and responded to. EVIDENCE: Progress had made in ensuring people using the service, have their needs identified and responded to in an individual plan of care. Diagnosed mental health conditions were more appropriately included. This had helped in ensuring a more consistent approach to providing support. People using the service indicated an awareness and involvement with their individual plans. Care plans seen, included much relevant information about peoples’ needs, abilities and goals, including rehabilitation and skill development, also very specific plans in response to behavioural needs and relapses. It was encouraging, that the care planning process was being used to work with individuals more effectively by focusing on positive outcomes. Systems were in place to regularly monitor peoples’ life and situation and reviews were being Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 14 carried out on a regular basis. One member of staff spoken with said they were aware of the care plans and their content. People living at Benjamin House were seen to be involved in many activities of daily living; for example, they were being consulted about day to day matters such as meals, drinks, shopping, outings, how they spent their time and other matters which affected them. Some care plans included separate agreements in relation to alcohol, smoking, and financial matters. The Expert by Experience considered people were being encouraged to make their own decisions and commented, “though they can be questioned by staff when genuine concern is an issue” staff had encouraged one person to think carefully about things and to give themselves time to consider their options in full. Attention had been given to ensuring individual risk taking is properly considered and planned for, positive interventions had been devised to minimise harm to the person and potential harm to others. This approach aimed to ensure safety risks are assessed, balanced with effectively promoting independence, rights and choices. General risk assessments had been carried out and also more in-depth risk assessments specific to individuals, including accessing the community, using public transport and eating out. Systems had been introduced to review risk assessments, in response to changes in peoples’ needs, behaviours and circumstances. The AQAA (Annual Quality assurance Assessment) indicated that ensuring care plans continue to be updated in response to changing needs, as a plan for ongoing improvement. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at Benjamin House were being supported to develop skills, engage in activities, use community resources and keep in touch with families and friends. EVIDENCE: People using the service spoke of the various individual and group activities they were currently involved with, including, local market, gym, pub library gardening. Mention was also made of people attending college courses, including health and fitness and IT, one person was due to attend a First Aid course along with staff. The Expert by Experience wrote, “There is much emphasis on social inclusion” one resident is “volunteering in the community at a gardening project Green Space and others attend college.” One senior support work was in the process of compiling a directory of community resources and activities, the AQAA (Annual Quality Assurance Assessment) Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 16 indicated that finding relevant and appropriate community resources for people to attend, as an area for further development. Records and discussion showed people’s relationship needs were being considered; people were being supported to keep in touch with families and others, as appropriate. Mention was made of weekly visits from family members and some people were having weekends away with relatives. Regular house meetings were being held to discuss choices and various opportunities, including- meals, menus, activities, holidays and outings. Independence living skills were being encouraged, people were responsible for keeping their rooms tidy, changing their beds, doing their own laundry, one person had organised a group outing. They could make drinks and snacks for themselves and were involved with shopping and cooking. One person told the Expert by Experience, “The staff definitely encourage independence, you’ve got to be focused to achieve your goal, independence is my goal and they encourage me towards it.” People spoken with said they were happy with the food at Benjamin House, “The food is very good” and “absolutely brilliant” were comments made, they said that menus were being agreed with them each week. Mealtimes were flexible, depending on what was happening each day. Individual food likes and dislikes were known and catered for. Fresh produce, including vegetables and fruit was seen to be available. Healthy eating was being encouraged and specific diets catered for. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Health and personal care practices and procedures were effective in ensuring people’s needs are properly and safely met. EVIDENCE: The care planning process included peoples’ agreed support needs in relation to personal hygiene. Interactions observed between the people using the service and staff, appeared sensitive; staff were respectful and genuine in their approaches when providing support and guidance. It was apparent from discussion and observation; people were generally being supported to take an interest in their appearance, hairdressing and clothing, individual choices were being encouraged. Records showed people were being supported to keep hospital, and other health care appointments, also the monitoring of general well-being and ill health. The Expert by Experience commented, about one person spoken with Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 18 “He receives the support he needs to keep appointments with statutory health staff, and a staff member will attend with him if he chooses” Mental health care needs were identified and responded to within individual care plans. Care plans also included a ‘health check’ assessment, with any matters being dealt with in consultation with appropriate health care professionals. Staff training had been provided in relation to specific health care matters such as schizophrenia and epilepsy. The AQAA (Annual Quality Assurance Assessment) indicated a lack of some health care related policies and guidance; this was discussed with the acting manager who had begun to address this matter. Discussion took place with the acting manager about the arrangements for smoking. It as suggested, the homes policy and practices be reviewed and agreed in the house meetings, with each persons specific needs and choices being responded to and agreed, in their individual plan of care. Medication storage facilities were satisfactory; clean and secure, temperatures were being monitored. Systems were in place to audit medication practices. Assessments had been carried as appropriate on peoples’ ability to manage their own medication; consent forms were seen agreeing to any staff support. Medication policies and procedures were seen to be available. Medication records seen were clear and accurate. The manager said all staff had received in–house medication training, records showed arrangements had been made for senior staff, to receive more formal training. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices, provided safeguards for people using the service and supported the complaints process. EVIDENCE: People were being encouraged to raise any issues within the weekly house meetings and the complaints procedures had been discussed. Systems were in place to manage more formal complaints. To assist the process, the acting manager was developing the recording format, to include the devising of investigation strategies. People using the service who had completed surveys and those spoken with during the inspection, indicated they knew how to make a complaint. The complaints procedure was included within the service user guide and a summary was displayed in each person’s room. The contact details of the Commission were also displayed in the hallway. Safeguarding policies and procedures were available. The acting manager expressed a good understanding of the action to be taken in relation to allegations, incidents and suspicions of abuse. Appropriate action had previously been taken to ensure support practices at Benjamin House provide effective safeguards for people using the service. POVA (Protection Of Vulnerable Adult) training had recently for some staff the acting manager said this training was to be ongoing. Two staff were due to receive ‘challenging behaviour’ training. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Most accommodation at Benjamin House provided people using the service with a comfortable and clean place to live. EVIDENCE: The Expert by Experience made the following comments about the home“The home itself was in my opinion a pleasant environment, though basic in décor, it was odour free and seemed very clean. The feel was a relaxing one and this was supported by a nice conservatory area; where the residents could choose to dine. There were many plants, pictures and ornaments that gave a homely feel to the place” People using the service expressed an appreciation of the accommodation provided; in particular their bedrooms. The lounge provided a very comfortable and well-furnished living space, new chairs had been provided in the dining Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 21 kitchen. Computer was available for people using the service and staff. People using the service had been consulted individually about the contents of their bedrooms. One bedroom was still seen to be in need of redecoration and refurbishment. The AQAA (Annual Quality Assurance Assessment) showed this room was to be upgraded to provide en-suite facilities, within the next 12 months. Observations, records and discussion showed most repairs to the home were being identified and responded too more effectively. The home was found to be clean and suitable laundry equipment was available. Some staff had an NVQ (National Vocational Qualifications) level 1 in cleaning and others were due to complete this training. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. For the benefit of the people using the service, Benjamin House should show continued good practice in relation to staff recruitment, staffing levels, training and development. EVIDENCE: Records and discussion showed staff training was being given attention at Benjamin House. The training matrix showed training had been provided, was ongoing or being planned for. Most staff had attained NVQ (National Vocational Qualifications) levels 2 or 3; others were working towards NVQ level 2. Courses such as First Aid, Fire Safety, Health and Safety and also more specialised training including ‘Approaches to Mental Health’, ‘Drug Awareness’ ‘Schizophrenia’ and ‘Epilepsy’ had been arranged and planned for. Equality and Diversity, also numeracy and literacy courses were also being arranged. The AQAA (Annual Quality Assurance Assessment) showed staff meetings were being held and staff training was to continue. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 23 People using the service made positive comments about the staff team they said: “I am greatly encouraged by staff in all aspects of living”, another commented, “Its nice to get some support from the staff but you need to get on with it…but staff help and you can have a laugh and a joke with them”. The staff rota showed satisfactory staffing levels were in place, and sufficient numbers of staff were on duty on the day the home was visited. Discussion took place about the action to be taken to ensure there are always sufficient staff on duty, as this still had not been clarified. The acting manager said that additional staff could be provided for various activities and support needs. Arrangements had been made to ensure there was always a senior staff on duty, to provide leadership in the absence of the manager. Recruitment records showed that, appropriate checks and screening had been carried out, references sought and interviews held. People using the service had been involved in selecting staff to work in the home. The induction training records of the new employee showed good systems were in place to provide information and instructions over a 12-week period, a training checklist was being completed and signed and dated by the employee and supervisor. The acting manager said, action had been taken to appropriately update the staff records and induction training found to unsatisfactory at the last inspection. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Benjamin House must continue to ensure effective leadership and good management practices, for the benefit and well being of the people using the service. EVIDENCE: The Commission for Social Care Inspection has ongoing concerns about the operation and management of Benjamin House. There has been evidence of historical erratic performance at the home, which has lead to a lack of sustained good practice over time. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 25 Since the last key (main) inspection there had again been changes in the management team at the home, and the home was currently without a registered manager. However, the registered manager form another home in the organisation was currently running the home and was to apply for registration at Benjamin House. This inspection showed progress in the general management of the home, including addressing previously made requirement and most recommendations. The acting manager had some suitable qualifications and had continued to develop her skills by accessing relevant training. This inspection visit showed the acting manager was enthusiastic, proactive and competent within her role. The acting manager said quality assurance surveys had recently been given to people using the service and relevant professionals. It was advised feedback about the service be reflected within the AQAA (Annual Quality Assurance Assessment). There was no Quality Assurance policy the acting manager therefore agreed to pursue this matter. The manager said the home owner had carried out unannounced inspection visits to Benjamin House, but there were no records of the reports available at the home and the acting manager had not received a copy. This meant it was still not clear that suitable arrangements were in place to show the home is being properly monitored, for the benefit of people using the service. Documentation was available to show that installations and equipment, such as appliances had been serviced, it was noted the electrical wiring was due to be re-inspected in April 2009 and there was no Gas Safety Certificate available, the acting manger agreed to take action in response to these matters. General health and safety risk assessments had been carried out. Records showed fire drills and fire equipment tests were being carried out. Fire risk assessments had also been completed. Arrangements were in place for staff to receive training in safe working practice subjects. A new accident procedure had been introduced. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 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 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 26 (5) Requirement To show the home is being properly monitored for the benefit of people using the service, reports following unannounced inspection visits by the registered person, must be available in the home. The registered manager must also be given a copy of the reports. Timescale for action 30/05/09 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. 2. Refer to Standard YA24 YA32 Good Practice Recommendations To provide a more pleasant environment for the occupant, one bedroom should be decorated and refurbished as soon as practicable. Staff should continue to be supported to undertake appropriate training, as specified by the National Minimum Standards for Younger Adults, so they have the appropriate skills and knowledge to support people living in the home. To ensure appropriate action is taken to cover staff absences. Suitable polices and procedures should be DS0000009525.V374607.R01.S.doc Version 5.2 Page 28 3. YA33 Benjamin House 4. YA37 5. 6. YA39 YA42 devised and introduced which provide clear instructions for staff to follow. To ensure people using the service benefit from living in a well run home, every effort must be made to ensure management practices/leadership are efficient and effective. An application for registered manager should be forwarded to the Commission as soon as possible. To ensure people using the service are central to ongoing development in the home, a suitable Quality Assurance policy should be devised and introduced. To show the home is being kept safe for people using the service, all maintence and servicing records should be readily available in the home. Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Benjamin House DS0000009525.V374607.R01.S.doc Version 5.2 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. 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