Inspection on 29/08/07 for Beacon Court

This inspection was carried out on 29th August 2007.

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

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

Other inspections for this house

Beacon Court 20/09/06

Beacon Court 06/12/05

Beacon Court 27/04/05

Beacon Court 05/10/04

Beacon Court 14/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Beacon Court 4 Church Road Dartmouth Devon TQ6 9HQ Lead Inspector Stella Lindsay Key Inspection (unannounced) 29th August 2007 1:30 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 Beacon Court DS0000051573.V344056.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. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beacon Court Address 4 Church Road Dartmouth Devon TQ6 9HQ 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) 01803 832672 01803 832672 Thurlestone Court Limited Vacancy Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (34), Old age, not falling within any other category (34), Physical disability (34), Physical disability over 65 years of age (34) Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD from age 50 years Date of last inspection 20th September 2006 Brief Description of the Service: Beacon Court is a large detached house situated on a hill in a quiet residential area, and on a bus route going into Dartmouth town centre. There are 29 bedrooms, five of which are large enough to be used as twin rooms, though all are currently in single occupation. Most have an en suite toilet. Many rooms have views over the town and countryside. Accommodation is on four floors. Three of the floors are accessed via a shaft passenger lift and there is a stair lift to the lower ground floor (bottom floor). Two rooms on the first floor require the resident to be able to negotiate two steps to access the rooms. There are two lounges, a dining room, part of which easily converts to form a quiet craft area. The conservatory leads on to a sun terrace, which has far reaching views over Dartmouth and the surrounding area. There is a garden area at the rear of the property and a car parking area at the front. The home cares for older people, including those with dementia. The home may also offer care for residents with physical disabilities from the age of fifty years. Because the residents have such a variety of needs and abilities, this is not a suitable place for people with challenging behaviour. The weekly fees range from £380 to £500. There may be a charge for escorted travel outside the home, including medical appointments. An up to date Service Users’ Guide may be obtained on request from the office, and the latest Inspection Report of the Commission for Social Care Inspection was on display in the entrance hall. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in August 2007. It involved a tour of the premises, and discussion with the Acting Manager, twelve of the residents, and five staff on duty. Prior to this inspection the Acting Manager had supplied information about the running of the home. Care records, staff files, health and safety records and the medication system were examined. The inspector visited some residents in their private accommodation, and spent time with others in the lounges and dining room. Staff and relatives had returned surveys and comment cards to the CSCI, and their views are represented in the text. What the service does well: What has improved since the last inspection? The Acting Manager had recently reorganised the communal rooms. The lounge with the large bay window now has a piano, and there is a television in the other lounge. Many residents independently told the inspector how pleased they are with the new arrangement. Nutritional assessments had been introduced, and provision of fresh fruit and vegetables had increased in order to promote residents’ good health. The medication system had been further improved, to ensure that residents continue to be given their medication correctly. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 6 A white board displays the menu of the day. This now includes the alternative to the main course that is available on request each lunch time. Call bells on pedants to be worn round the neck have been provided for some residents, so that they will be able to call for help wherever they are sitting, without any trailing lead. Benches had been provided for the balcony, and an awning was due to be delivered, to encourage residents to enjoy the fresh air and scenery. The hours worked by a cleaner had been increased, to maintain better cleanliness throughout the house. The recruitment procedure had been followed rigorously, with all checks made, to assure protection of residents from potential harm. 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. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 7 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 Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 8 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): 1,3 Quality in this outcome area is good. Clear information is provided for prospective residents and their families, and the admission process continues to be carefully managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Court Group provide a brochure which contains information about all the homes they provide. They also have a website, and a brochure can be freely obtained. Beacon Court has its own Statement of Purpose and Service Users’ Guide, clearly presented and available on request from the office. Included is a chart showing the results of this year’s Residents’ Survey, showing a range of views residents gave about the service they had received. Visits to the home are welcomed. Short stays and respite care are offered, and all admissions are initially on a trial basis. There is a brief assessment form which is completed before any admission. This highlights any potential risks that need to be managed, to ensure that care and accommodation are offered appropriately. The decision to offer Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 9 accommodation should be confirmed to the resident or their representative in writing, whatever the length of their proposed stay, and the Acting Manager agreed to prepare a standard letter. When an admission is expected to be long term a more comprehensive assessment form is completed, to contribute to the care planning. The care records of two recently admitted residents were examined. One had been an emergency admission, and information had been provided by a Social Worker and the hospital. This resident had known the home from previous visits to a relative. The other had been visited by the Acting Manager in their previous accommodation, in order to carry out the assessment of needs, and ensure that the placement would be suitable. Assessment was continuing within the home, to ensure appropriate support. Intermediate care is not offered at Beacon Court. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. Residents are well cared for in respect of their health and personal care needs. Medication is carefully administered, to promote residents’ health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans of three residents were examined, and it was seen that sufficient detail was included for staff to know what help residents needed in different areas of their lives, including social care needs as well as health, personal care and nutrition. The care given to residents was discussed with staff on duty, and the knowledge and competence of the team of Senior Care staff was seen to underpin a sound service to the residents. Risk assessments had been carried out, including moving and handling assessments, prevention of falls, and vulnerability to pressure areas. Such good practice had been maintained that a resident had remained free from pressure sores through long-term weakness and immobility. Information on tissue viability was available for staff, and pressure relief was currently their ‘Policy of the Month’. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 11 Bed rails were in use for three residents. Health professionals had been consulted, and risk assessments carried out. This had in one case lead to recognition of a risk to the resident’s safety, and an extra piece of rail was obtained to deal with this. There was evidence in care records of collaborative work with District Nurses. Staff were seen using moving and handling techniques in a safe manner. The home has a medication policy and procedure, and staff were seen to be administering it with care and competence. Storage was secure, and records were accurate. There were divider sheets between residents’ records, with their vital details, including GP and any allergies, and a photo to ensure staff always identify the right person. This new feature shows continued effort by staff to maintain good practice. Nutritional assessments were carried out. The Acting Manager had published an article in a professional journal, describing the importance of good nutrition in promoting good health for residents, and was implementing her knowledge at Beacon Court. She said that the use of laxatives within this home had been reduced, as well as some infections, following the raising of residents’ consumption of fruit and vegetables, and that improvements in nutrition and hydration were shortly to be independently evaluated. All residents’ individuality and dignity was noted as being upheld, with staff speaking sensitively and kindly to residents. Suitable locks had been fitted to bedroom doors, for privacy and security. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 Quality in this outcome area is good. A good variety of social activities is provided within the home, responding to the abilities and interests of residents. Links are encouraged and maintained with the local community. Good meals are provided with the emphasis on fresh fruit, juice and vegetables. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents who spoke to the inspector were satisfied with their daily routines, including their weekly bath. One said they would be able to have an extra shower if they wanted. The more independent people said they are able to get up and go to bed when they want. Residents may have a breakfast tray taken to their room. Social activities were provided within the home once or twice every day. The programme for the month was on display, and copies had been given to residents. Activities had included personal attention such as manicures, foot spas and hand massages. There had been word games and quizzes, and exercise sessions. A record had been kept to show which residents had joined Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 13 in, which staff had lead the activity, and what had been done, to show that a good variety was provided. Visiting entertainers had been engaged. Residents were pleased that a piano had been provided. Staff and Management were anticipating Music Therapy, which had been arranged to start the following month, with a qualified teacher. Residents who were not easy to engage due to their level of confusion had been seen to respond well to music, and this new activity was particularly to promote their social engagement and well-being. The home is commended for making this new and exciting provision. An annual visit by the Old Dartmothians had been in full swing when this inspection started, marking the start of Regatta Week. Residents were very much aware of local events, some of which could be observed and enjoyed from the windows and balcony. The home used to share the use of a minibus with other homes in the Group, but this is no longer available, and residents were not getting out unless they could go out independently or had family or friends to take them. The Church of England Vicar visits monthly for Holy Communion, and the Baptist Minister also visits monthly to hold a service. Visitors are welcomed and encouraged and the home’s visitor’s book evidenced many visits from different people at various times. To ensure that residents are offered five portions of fruit or vegetables each day, fruit is often prepared and offered with morning coffee as an alternative to biscuits. Lunch during this inspection was fish, with sauce (if wanted), with mixed vegetables and potatoes. A milk pudding with tinned peaches followed. One resident had a gluten free and dairy free alternative. Residents said they enjoyed their meals, and two praised a Senior Carer’s jacket potatoes! One said they often have to wait a long time to be served, while another said that each table takes turns to be served first. One carer quietly helped residents who needed support, and was pleased to report that they ‘ate all their dinner’. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 14 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): 16,18 Quality in this outcome area is good. Residents are protected from harm by the home’s policies and procedures, staff training and positive attitudes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaint policy was displayed in the hallway, and is also contained within the information given to prospective residents. Residents stated that felt they could easily approach the manager or any staff member, if they were to have any concerns. ‘They would deal with it immediately’, one said with confidence. The CSCI had been informed of a complaint made by a relative. The Acting Manager was in the process of dealing with it in an effective and timely manner. A record of minor concerns had been kept, but its use had lapsed. It would be good practice to bring this back into use, so that people know that their concern has been heard, and what action, if any, has been taken. Abuse awareness is included in the home’s induction training for new staff, with a video and question sheet, to show that it has been understood. Residents paid tribute to staff attitudes – ‘staff deserve the highest praise’, with their kindness and understanding of residents. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 15 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): 19,20,21,26 Quality in this outcome area is good. Work has continued to maintain this home as a safe, comfortable and interesting place for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour of the home confirmed that the home owners maintain very good environmental standards within the home, which makes Beacon Court a pleasant place to live in. The Court Group’s health and safety officer visits every six weeks, to check for any remedial work that needs to be done to maintain the required environmental and health and safety standards within the home. Security of residents within the home is monitored, and some external doors had been fitted with keypad locks. Routine general upgrading continues to take place as required. A maintenance worker had been recruited, and was painting bedroom doors at the time this inspection started. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 16 Beacon Court is a large house built on a hillside. There is level access to the main entrance from the car parking area at the front. The lower ground floor is in two sections, one part accessed by a stair lift. Some bedrooms on this floor have patio doors, where residents may have direct access to the garden, and some had seats here. The Acting Manager is planning to improve access to the garden, and provide a paved and gated area to encourage residents to use it in safety. The other outside space available for residents is a balcony, accessed through the conservatory, which has stunning views across the town, harbour, and countryside. Benches had been provided, and the Acting Manager said that awnings were on order, and due to be fitted. The ramp to enable access from the conservatory was wobbly. It should be more stable, to encourage people with mobility problems to use it. The two lounges, dining area, and conservatory are joined together in open plan, but laid out and furnished in such a way as to give an interesting choice of places to be either quiet or sociable. Residents were pleased with the new lay-out of the lounges. The television had been put in the darker lounge, while the lounge with a very large bay window overlooking the valley, had been rearranged with a piano and pot plants, and residents appreciated the different ambience. There were two bathrooms and a shower, equipped for people with mobility problems, and arrangements were being made to install another shower in the lower ground floor, to increase choice and availability of facilities. Good locks had been fitted to bedroom doors, for privacy and security. Lockable boxes can be made available to any resident who is able to use one for the safekeeping of valuables. The house was clean throughout. There was a slight odour in two rooms, due to particular problems, but efforts were continuing to combat this. Toilet walls had been lined with plastic tanking to assure that they are easily cleanable. The system of soluble bags was in use for soiled laundry, to keep it separate from clean clothes and avoid cross contamination. This is important, because the laundry is small, and residents’ clean clothes are gathered in open boxes on shelves before being returned to their rooms. Staff receive regular cross infection training as part of the Court Group’s statutory training programme. During the inspection it was noted that disposable gloves, paper towels and liquid soap were available for regular use. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30 Quality in this outcome area is good. Competent and caring staff are employed in sufficient numbers to meet the assessed needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A written rota is kept, which shows that at least one Senior Carer is on duty between 7am and 8pm. There are four care staff until 2pm, and three during the afternoons. At night there are two care staff on duty, both awake. There is an extra helper at teatime. This level of provision was seen to be sufficient to meet residents’ personal and health care needs, and to provide social activities within the home. One relative returning a survey, said they felt the home was understaffed, but another visiting at the time of the inspection observed that ‘there are always staff around’. A cook is employed 8 – 2pm every day. The cleaning hours have been increased and a full time housekeeper is now employed. A part time maintenance worker has been appointed. A gardener is engaged as necessary. Staff have continued to work towards achieving the nationally recognised qualification known as National Vocational Qualification level 2 in care, and three more were hoping to register to do this, to enhance their competence and maintain a qualified workforce. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 18 The files of two recently recruited staff were examined. It was seen that all checks had been made to assure protection of residents from potential harm. The home has a regular training plan, with a qualified trainer employed by the Court group who is provided with information as to the staff’s training needs. There is a thorough induction training for new staff. They have a workbook to complete, and the Manager signs for each section when they consider that it has been understood and mastered. This was seen completed on staff files. Mandatory training is provided, with monthly sessions. Records were seen of training delivered recently in Fire Safety, Moving and Handling, Safe handling of Medication, and Nutritional assessment. A session on Communication was booked for the week following this inspection, and a six week accredited course on the care of people with dementia was on offer to some staff. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38 Quality in this outcome area is good. The home provides a safe, secure environment where residents’ safety and well-being is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Good management was being maintained while the home awaited the arrival of a newly appointed Manager. One of the Directors, Brigitte Harvey, who has a qualification in Management of Care, and who normally provides support to the Manager, had stepped in as Acting Manager. Mrs Harvey was maintaining safe systems of work, and implementing improvements as described earlier in the text. The home owners gather feedback from staff annually, and this was due to be carried out again in October. Staff meetings are held. The most recent records seen were of a meeting in January 2007 when several safety issues Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 20 were discussed. Investors in People accreditation had been achieved in November 2004 and its review was anticipated during the autumn. Feedback is also gathered from residents, and their views are presented in the information available for prospective residents. There were records of Residents’ meetings in June and February, when menus, activities and a gardening club had been discussed. Mrs Harvey normally carries out a formal monthly in-depth review of the service and provides the manager with a written record of this visit as required under regulation twenty-six, (though not while she is herself managing the home). These processes ensure that the home continues to be run in the best interests of the residents. Small amounts of cash were held for safety on behalf of 22 residents. Only the Manager has access to these funds, to assure security. The system of recording was sufficiently sound, that it could be seen that residents’ money was safeguarded, although the balance sheets were not up to date. Residents’ valuables are listed when they move in to the home. It was not clear whether jewellery worn at the time had been included. This procedure should be clarified. A good system of conducting supervision sessions for staff had been introduced under the previous Manager. There is a systematic way of covering important topics, considering the staff member’s performance, and coming up with an action plan for their development. Sessions had lapsed in the interim period, but would be expected to recommence following the arrival of the incoming Manager. Safe systems of work were seen to be maintained. Fire training and risk assessments had been carried out by a member of the Court group staff, who is employed specifically to ensure that this, and all other areas associated with the health and safety of the residents, are maintained in accordance with the requirements associated with each health and safety area. All fire doors, including bedroom doors have closers to make sure that they shut properly, so as to effectively protect the occupant in an emergency. If any resident wishes to have a ‘dorgard’ fitted, so that they can keep their door open during the day while they are in it, a charge will be made. The home should complete its policy by being clear about what should happen when the occupant moves out or no longer needs the ‘dorgard’. The home’s fire log book was inspected and found to be in order. Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 22 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. 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. Refer to Standard OP16 Good Practice Recommendations A record of minor concerns had been kept, but its use had lapsed. It would be good practice to bring this back into use, so that people know that their concern has been heard, and what action, if any, has been taken. The ramp which is to enable access from the conservatory to the balcony should be more secure so that people feel safe when walking over it. The home should complete its policy with regard to the installation of approved hold-open devices for fire doors by being clear about what should happen when the occupant moves out or no longer needs the ‘dorgard’ 2. 3. OP19 OP38 Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Beacon Court DS0000051573.V344056.R01.S.doc Version 5.2 Page 24 - 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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