Inspection on 09/02/09 for The Beacon

This is the latest available inspection report for this service, carried out on 9th February 2009.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE The Beacon The Beacon Solomon Court Cleethorpes North East Lincolnsh DN35 9HL Lead Inspector Jane Lyons Key Unannounced Inspection 09:00 9th February 2009 X10015.doc Version 1.40 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 The Beacon DS0000072599.V373954.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 Older People. 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. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beacon Address The Beacon Solomon Court Cleethorpes North East Lincolnsh DN35 9HL 01472 325405 01472325404 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) North East Lincolnshire NHS Care Trust Plus Jay Sadler Care Home 30 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (30), Physical disability (30) of places The Beacon DS0000072599.V373954.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: Old age not falling within any other category - Code OP maximum number of places, 30 Dementia - Code DE, maximum number of places, 30 Physical disability - Code Pd, maximum number of places, 30 The maximum number of service users who can be accommodated is: 30 2. Date of last inspection Brief Description of the Service: The Beacon is a care service run by North East Lincolnshire Care Trust Plus and is situated in central Cleethorpes. The main aim of the centre is to provide intermediate care support in partnership with the community nursing, therapy and care management teams. People stay for a limited period and the service is geared to the physical improvement and support of people who have been ill or who have a disability, prior to them returning home. The service continues to provide long term care support for one individual however this service is gradually being phased out by not admitting any more people who require long term support. The building is all on one level and divided into four units. There is currently a major works programme in progress to upgrade and refurbish the majority of the facilities. Completed work is to a high standard. All bedrooms are for single occupancy, four en-suite facilities are provided. There is a good range of communal areas and bathing facilities on each unit. The home has a range of equipment to meet the care and rehabilitation needs of the people who stay in the home to ensure their independence is maximised; there is a therapy gym and kitchen and a wide range of specialist equipment in the home. Two of the bedrooms have been specially equipped for people who have specialist needs around their weight and or size. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 5 The grounds are well maintained and there is car parking space at the front of the property. Information on the service is made available to prospective and current individuals via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are always held in the reception area. There is no charge for persons admitted for intermediate care support. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing, chiropody and incontinence aids additional to allowances. The Beacon DS0000072599.V373954.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 3 star. This means the people who use this service experience excellent quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) from the last six months including information gathered during a site visit to the home which took approximately seven hours. This service was registered with North East Lincolnshire Care Trust Plus in August 2008 and as this is the first inspection of a newly registered service all the thirty eight national minimum standards have been assessed. As part of this inspection process surveys were sent out to ten people using the service and ten staff who work there. Surveys were received from seven staff members and four individuals. Comments were very positive such as ‘Excellent service’ and ‘They look after me very well’. Anonymised comments from surveys and from discussions on the day of the site visit will be included throughout the report. Throughout the day we spoke to people staying in the home to gain a picture of what life is like at The Beacon during their stay. We also had discussions with the registered manager, the intermediate care manager, care staff, the cook, relatives and community nursing and therapy staff. We looked at assessments of need made before people were admitted to the home and the home’s care plans to see how those needs were to be met while they were staying there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff recruitment, staff training, how the home monitors the quality of service provided and how the home is managed overall. We also checked with people to make sure that privacy and dignity is maintained, that people can make choices about aspects of their lives and that the home ensures they are protected in a safe, clean environment. We observed the way staff spoke to people and supported them and checked out with them their understanding of how to maintain privacy, dignity, independence and choice. We would like to thank the people who were staying at The Beacon, the staff team and the management for their hospitality during the visit and also thank the people who spoke with us. This was a very positive and enjoyable visit. We have reviewed our practice when making requirements, to improve national consistency. In future if a requirement is repeated it is likely that enforcement action will be taken. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? This is the home’s first inspection under the new registration. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 8 What they could do better: 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. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home provides detailed information to enable people to make an informed choice about the services they provide. People’s healthcare and rehabilitation needs are fully assessed before they are offered a service. People are supported to maximise their independence and return home where possible. EVIDENCE: There is an up to date statement of purpose and service user guide available for people. Copies of these documents have been provided to the social work The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 11 team at the hospital to give to people to assist them in making a decision about accepting short term rehabilitation support at the home. Records show that people who are admitted to The Beacon for intermediate care support sign Consent and Working Together Agreement and also a Statement of Terms and Conditions document. There are no charges for this service. We looked at a sample of files, which belong to people who are staying at the home, and we saw that these contained copies of assessments undertaken by the care management team and the home. The assessments cover all aspects of health, personal and social care needs. In addition to this, information is also requested from the family and health and social care professionals where possible so that the home has as much information about the prospective individual prior to their admission. All of the information gathered at the time of admission is collated and used to develop an individual care plan for each person which clearly identifies all their rehabilitation and support needs. People spoken to confirmed that they were involved in their assessments and have a say in what happens to them. One person said ‘I’ve stayed here before, they looked after me really well and helped me to return home’. People are admitted to the service from hospital following a stay or an emergency admission to the accident and emergency department, they are also admitted from the community following a crisis or a period of illness. Given the admission route of the majority of people there is little opportunity for them or their relatives to visit the service prior to moving in, however the home would accommodate this where possible. The returned surveys show people are very happy with the services provided and were given enough information prior to their admission. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 ,10 and 11 People who use this service experience excellent outcomes in this area. We have made this judgement using available evidence including a visit to this service. People’s rehabilitation needs are well met and they receive excellent standards of care. The medication systems in the home are well managed and people are supported to gain their independence with their medication administration where possible. People have their privacy and dignity very well upheld and respected. EVIDENCE: People were observed being treated with dignity and having their wishes respected throughout the visit, we saw that staff are sensitive to people’s needs when carrying out personal care support and sensitive and patient when dealing with those people who have some memory loss problems. People spoken with told us that they their needs were being met and they are very satisfied with the support they receive, some of the comments included ‘The staff here are excellent, nothing is too much trouble’ and ‘They look after us very well, I’m making such progress I should be home soon’. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 13 We looked at three people’s care files in detail which show that they are fully involved in their assessments and have a say in what happens to them. The files have assessments and risk assessments in place in order for staff to formulate plans of care. The information in care plans show that people staying in the home have their own preferred routines and discussions with staff and records show that people are assisted and supported by staff to make decisions and choices about all daily living needs. The documentation system has been reviewed and improved since the last inspection visit, therapists, nursing staff and care staff now complete a single daily record which provides a current account of the care and therapy support they have received. Care plans are produced by the care and therapy staff which are detailed and direct staff on the actions they need to take to meet the needs of the people they care for. The plans are person centred and all therapy programmes are targeted to meet people’s individual needs. The records show that the care plans are updated regularly, formal meetings are held weekly by the care and therapy staff to discuss each individual’s progress, current care needs and plan the individual’s discharge arrangements effectively. There are risk assessments in place for mobility, tissue viability, medication, nutrition, falls and general issues. Records show that the risk assessments are reviewed regularly and where high risk areas have been identified, care plans are in place to support appropriate care provision. We also looked at the care file for the remaining individual receiving long term care support in the service; the care plans were up to date and well maintained. Daily records are detailed they describe how the individual’s health and personal needs have been met and also describe in detail how the individual has spent their day and what they have enjoyed. We spoke to the individual’s key worker who has clearly developed a very positive relationship with the person and knew his needs very well. There was very good evidence at this visit that the staff at the home have continued to build on the positive working relationships they have with the community nursing and therapy staff to provide an excellent enabling service for people. We spoke to a number of health professionals during the visit and some of their comments include ‘The staff are always friendly and work well with us’ and ‘The staff are always keen to implement any recommendations and follow the enablement programmes really well, the standards of care are very good, they are a very tight team’. The way medicines are handled and stored in the home keeps people safe. The staff make sure that the correct medication has been brought in with the individual on admission and any omissions are quickly followed up. The staff make sure that the recording of the medication is up to date and storage seen The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 14 is well managed. Storage of controlled medication was also checked and found to be satisfactory. It is one of the home’s main objectives that people are supported to regain and maintain their independence with medication administration; there was good evidence that all individuals are assessed for self- medication on admission. Records showed that the majority of people were self- medicating with assistance; monitoring procedures in the home are very robust. Interviews with senior staff confirmed that the home achieves very positive results with enabling people towards independence with their medication administration. All of the staff who give out medication have had the proper accredited training and we saw certificates which confirmed this. There are systems in place to support end of life care at the home, the manager confirmed that the home has utilised specific documentation “The Liverpool Pathway of Care” in line with the community health care team to support people’s palliative care needs. A number of the staff have recently completed distance learning courses in palliative care and the unit manager has responsibilities within her extended role to promote the need for excellent standards of end of life care across the Directorate. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People have a say in what happens to them and a range of activities are provided to support their social needs and to improve their life skills. People enjoy a varied and balanced diet of their choice. EVIDENCE: When we spoke to people who stay at the home they said they could make choices about activities, food how to spend their time and when to get up and go to bed. The home encourages contact with friends and relatives, we saw that visitors are made welcome to the home and have good relationships with the staff. Visitors spoken with during the day told us that the staff are very kind and friendly. People’s social, religious, recreational and psychological needs are identified in assessments and care plans. We saw that a selection of activities are arranged for people to take part in if they wish; these included Bingo, games, singalong’s, manicures, DVD’s, jigsaws and outside entertainers. The staff also provide a programme of chair based exercises which they said are very popular, two of the care staff have completed courses to provide this type of therapy. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 16 The manager confirmed that the home has a range of reminiscence materials, new board games and a new Wii console which would be included in the activity programme in April. One of the senior care staff has the lead responsibility for arranging activities and maintains records of people’s participation in the programme. People spoken to told us that they enjoyed the activities provided and also enjoyed sitting in their rooms watching T.V. or reading. Records in the care file for the individual who resides long term at the home show that he accesses regular trips out with his key worker for shopping and lunch. The key worker told us that they were arranging a shopping trip to buy a new bed and some new bed linen, she also told us about and showed photographs of a recent holiday in Skegness which they had both enjoyed. When we spoke with the people who live at the home about the food they told us that it was very good and there is plenty of choice. Lunch on the day of the inspection was nicely presented and looked wholesome and nutritious, serving dishes are provided to enable people to help themselves where possible. Although none of the individuals seen required assistance with eating, staff were always on hand to provide support and offer ‘second helpings’. The cook visits each person daily to discuss menu choices. When we spoke with her she was knowledgeable about people’s diets and confirmed that diet sheets are now provided to the kitchen which detail individual’s specialist dietary needs and also their preferences. Records show that some of the care staff have accessed a distance learning course in nutritional awareness and the cook has accessed specific training around the nutritional needs of older people. Following the inspection, the manager provided information that the kitchen areas in the home had achieved a five star rating from the Environmental Health Department. This is a very positive achievement. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home has systems in place to protect people from abuse. People can be confident that their complaints will be listened to and acted upon. EVIDENCE: People who completed surveys responded ‘yes’ when asked if they knew how to make a complaint. Those people spoken with during the day also confirmed they knew who to go to if they were unhappy about something. The complaints procedure is displayed in the front entrance of the home. It is also available in the home’s service user guide, a copy of which is provided in each individual’s bedroom. Information provided by the home prior to the visit shows that the home has not received any complaints within the new registration. The Commission have not received any complaints about this service. Discussions with the manager evidenced that there are systems in place to support the investigation and management of complaints. People also now have the opportunity to access the Patients and Liaison Service (PALS) which is NHS run and works closely with the Customer Care Department at the Care Trust Plus. This information is also included in the Service User Guides. There were a number of ‘thank you’ cards displayed in the front entrance of the home. The cards are from relatives of people who once stayed at the home The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 18 who were thanking the staff for their care and kindness during their loved ones stay at the home. Information about advocacy services is displayed in the reception area, there is also a range of other information leaflets for people who use the service and their relatives to access such as information about benefits and support groups. Senior staff have accessed training on the Mental Capacity Act and this is being rolled out to the remaining staff in this years development programme. When we spoke with the staff they were able to tell us what they would do if they witnessed any abuse within the home or if anyone made any allegation to them. To protect people receiving a service, staff training records show they have all attended safeguarding training. Staff were observed throughout the visit listening to what people said and treating them with dignity and responding to their wishes. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 ,20, 21, 22, 23, 24, 25 and 26 People who use this service experience excellent outcomes in this area. We have made this judgement using available evidence including a visit to this service. The Beacon provides people with a very comfortable, clean and safe environment. There is a wide range of equipment available to meet people’s rehabilitation needs. EVIDENCE: The home provides spacious single accommodation on one floor. The home is divided into four units each having its own bath/ shower facilities, bedroom facilities, dining area, sitting room and kitchenette. At the time of the visit the home was undergoing a major refurbishment programme which includes replacement of the water and heating systems, new roof, windows, upgrading of all bedrooms, bathrooms, sluice areas, communal areas, entrance hall and kitchenettes. Four of the bedrooms will be provided with en-suite facilities and two bedrooms in House One have been fitted with equipment for persons with The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 20 specialist needs due to their size and or weight, such as larger beds, overhead tracking for moving and handling purposes and wider style chairs and commodes. The staff and people who use the service are having to cope with some significant disruption whilst the works programme continues and from observation during the day we saw that everyone was dealing with the situation very well. Upgrading work to half of the unit has been completed and these facilities are in use, people told us that the noise from the workmen didn’t really bother them and the machinery in use often affected the reception on the TV’s but this was understandable. The fire alarm was activated twice due to the impact of the works programme on the homes system, on both occasions we observed a good response from staff. The manager has put in place a number of new environmental risk assessments which support all the work taking place and potential hazards, which better protects the safety of the people who use the service and the staff during this time. The works programme is scheduled for completion in April when all the units will be reopened for use. We looked around the home and found that the quality of the upgraded facilities to be very good, décor and furniture throughout reflect a contemporary, homely style which provides very comfortable and pleasant accommodation. Photographs of the local area, that is Grimsby, are placed in the hall and corridors to provide a focus for reminiscence and discussion. All areas of the home are well lit the lighting is domestic in style. There are a variety of bathrooms and shower facilities on each unit which are well equipped. Corridors and doorways are wide to accommodate wheelchair users. Grab rails have been provided in corridors, bathrooms and toilets. A ‘Loop’ system has been fitted in one of the lounges which provides assistance for people with hearing problems. The home has a range of equipment to meet the care and rehabilitation needs of the people who stay in the home to ensure their independence is maximised; there is a therapy gym and kitchen and a wide range of specialist equipment in the home. Bedrooms have been redecorated and refurbished to a good standard; four of the bedrooms will have en-suite facilities. All bedrooms will be provided with ‘Profile’ style beds by April. Each unit has a dining area with servery attached. There are a range of lounge areas in the home where people can choose to sit and spend their time, the manager confirmed that a large digital plasma television will be provided on the wall in the largest lounge area, making easy viewing for those people who may have sight problems. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 21 Laundry facilities are sited appropriately. Policies and procedures are in place for control of infection. Records show that all staff have accessed training and updates in this area. The community infection control team have visited the home in recent months and provided guidance on best practice which staff have implemented. The home was spotlessly clean and tidy and there were no unpleasant odours noted in any areas of the home. People who completed surveys said the home is ‘always’ fresh and clean. The home is situated in a quiet residential area which backs on to parkland. In the central area of the home there is an enclosed courtyard and small garden that makes a pleasant area for people to sit out in the warmer months of the year. The atmosphere on the day of the visit was warm and friendly and people looked comfortable whilst sitting in various parts of the home. People spoken with said how pleased they are with the home and the facilities available. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People are cared for by well- recruited, well trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy a good service of care. EVIDENCE: Discussions with staff and people who use the service and from observation during the day evidenced that there are enough staff rostered to meet people’s needs, staff told us they had enough time to carry out their tasks and spend time with people. Although the home has only had two of the units open in recent months there was evidence that the dependency needs of people admitted to the service had increased significantly and the service had remained very busy. Health professionals spoken with during the visit confirmed this, comments included ‘Many people admitted to The Beacon have very complex needs, they are often too ill to accept enabling support when first admitted, they are staying longer and require much more support from the staff’ and ‘We are accepting clients with greater needs, the staff are coping really well, but it means the service is even busier’. The home has implemented their own staffing dependency tool which identifies how many staff are needed on each shift, the staff spoken to confirmed that this worked well and the management always ensure enough staff are rostered to meet people’s needs and run the service effectively. Discussions with the manager The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 23 during the visit confirmed that the management team were already looking ahead to when the unit is fully opened and the impact this will have on the current staff base and workload, work is in progress to develop a new dependency tool which will support effective staff rostering. Surveys returned from staff included ‘The knowledge and experience of my colleagues at The Beacon is excellent’ and ‘The staff group here are the most comprehensive I have ever worked with’. Ancillary staff are employed to provide catering, domestic, laundry and administrative tasks at the home. This enables care staff to concentrate on personal, physical and emotional care with people who use the service. All people spoken with were very complimentary about the staff and they said that staff are always available when needed, comments included ‘The staff are all very kind and caring’ and ‘The staff are wonderful’. New staff complete an in-house induction programme. Following this, they complete the Skills for Care common induction standards to assess their competence which is signed off by a Senior Care Officer on completion. Information provided by the manager before the visit shows that the home has maintained the target of having 50 of care staff qualified at NVQ in care at level 2 or 3, the current figure is 77 and four staff are currently working towards this qualification. There is a training and development plan in place that shows all staff have undertaken core training and that some staff undertake more specialised training such as palliative care, dementia and nutrition. Training consists of inhouse DVD’s, distance learning, in house sessions from the health professionals and courses provided by the workforce development team at the CTP. Records show that the staff are up to date with mandatory courses such as first aid, moving and handling, basic food hygiene and fire safety. We saw that staff records include information about individual training achievements and a copy of training certificates is kept on their file, some of the files seen did not have all the certificates in place which should be addressed. All the staff are scheduled to receive training on enablement in the coming weeks. Staff receive regular supervision and developmental opportunities are given for the staff to attend further training. Comments from staff include ‘Our training schedule is excellent, if we request some training that we feel we need to do then it is sorted’ and ‘A wide range of training is available’. The recruitment and selection procedures at the home are robust and all checks are undertaken prior to staff commencing work at the home, this protects the people that use the service. The staff files looked at contained The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 24 references from previous employer, an application form which identified any gaps in employment and a completed Criminal Record Bureau (CRB) check. The retention practices at the home are very positive, staff turnover figures are low. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. People who use this service experience excellent outcomes in this area. We have made this judgement using available evidence including a visit to this service. The ethos, leadership and management approach benefits people using services. People’s opinions are central to how the home develops and reviews their practice. The environment is safe for people and staff because robust health and safety practices are carried out. EVIDENCE: The manager is registered with the CSCI and has many years experience in managing care services for older people. The manager is suitably qualified which includes appropriate management qualifications and the Registered The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 26 Manager’s Award and has extensive, relevant knowledge, skills and experience. She is committed to ensuring the service provides excellent standards of care for people and has cultivated a very positive ethos amongst her staff. The home’s management structure includes Senior Care Officers, the impression was formed of a cohesive senior team providing good direction and leadership to staff and of good teamwork. Observations confirmed the management of the home was efficient despite current constraints from the works programme. People who use the service told us that the management are approachable and the home is run very well. Staff told us that the management is very supportive and provides them with good leadership. Comments from staff surveys include ‘Jay Sadler, unit manager is great. She has a terrific relationship with her staff’ and ‘I feel I have very good support from my line manager and unit manager’ and ‘The manager is very supportive, her door is always open’. The home works very closely with the community nursing, therapy and care management teams to provide intermediate care services for people, comments from some of these professionals spoken with during the visit include ‘There is a real sense of partnership between the unit staff, therapists and wider healthcare team’ and ‘The unit is managed very well, we have a good relationship with all the staff and share the same ethos of supporting people to return home’. Following the registration of the service under the Care Trust Plus many of the management systems have changed or are in the process of changing, these include the staff appraisal systems and the quality assurance systems. All the home’s policies and procedures are currently being reviewed. The home consults with the people who use the service on a regular basis, quality surveys are issued to all people on discharge and during their stay they can attend regular carers/ residents meetings. The manager confirmed that they are in the process of reviewing the surveys they issue and will be including ones for staff and stakeholders. The management team carry out regular audits of key areas and action plans are developed to support any areas of deficiency identified. A full audit report is produced based on the findings of the surveys which also includes a lot of the corporate statistical data, advice was given to produce a simpler report which better describes the changes made from all the consultation with people and the direction the service is going and the improvements the service is planning to make over the next twelve months. The homes business and financial plan and insurance arrangements were in place and submitted to support the home’s registration in 2008. There is evidence that the responsible individual visits the service regularly. Reports to support these visits were available for March, July and October The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 27 2008, the manager needs to ensure that copies of all reports are held in the home. The staff supervision and appraisal programmes have been well maintained with evidence that the staff are receiving the appropriate number of sessions and that they are linked to the staff development programme. Regular staff meetings are arranged. The home only manages the personal finances relating to the one individual who has permanent residency in the home. The account was looked at and found to be in order with receipts in place to support all transactions. The home is a safe place to live and work in, the manager has ensured that the current works programme has not compromised any of the safety measures or safe working practices in place at the home. There is a fire policy and the risk assessment has been updated to include the current works programme. Tests on equipment are undertaken and regular fire drills for staff are carried out. During the visit we observed a positive response by the staff to the fire alarms. All the equipment in the home is tested at the appropriate intervals and all maintenance certificates are up to date. The AQQA which was returned by the home prior to the site visit was well completed and told us about identified areas for improvement. The staff are trained in health and safety and their mandatory training is updated as required. Accidents in the home are audited by one of the senior care officers; records are maintained of action taken to further reduce the risk of reoccurrence. The home liaises with the community falls co-ordinator where necessary. The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 3 4 3 3 4 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 4 3 4 The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 OP30 OP33 Good Practice Recommendations Staff files should contain all certificates relating to the training courses they have attended. The home should produce a simpler quality report which describes the changes made from all the consultation with people and the direction the service is going and the improvements the service is planning to make over the next twelve months. Copies of all reports to support the monthly visits by the responsible individual should be kept in the home. 3. OP37 The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 The Beacon DS0000072599.V373954.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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