Inspection on 18/09/06 for Beacon Edge Nursing Home

This inspection was carried out on 18th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Edge Nursing Home 09/11/09

Beacon Edge Nursing Home 04/12/07

Beacon Edge Nursing Home 22/11/05

Beacon Edge Nursing Home 20/07/05

Beacon Edge Nursing Home 25/01/05

Beacon Edge Nursing Home 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Beacon Edge Nursing Home Beacon Edge Penrith Cumbria CA11 8BN Lead Inspector Marian Whittam Unannounced Inspection 18th September 2006 10.00a 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 Edge Nursing Home DS0000010094.V304742.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 Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beacon Edge Nursing Home Address Beacon Edge Penrith Cumbria CA11 8BN 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) 01768 866885 01768 899044 deankath@bupa.com www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Mrs Kathleen Mary Jane Dean Care Home 41 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (36) of places Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 41 service users to include: - up to thirty six service users in the category of DE(E) Dementia over 65 years of age - up to five service users in the category of DE (Dementia under 65 years of age The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 22nd November 2005 2. Date of last inspection Brief Description of the Service: Care First Care Homes Limited, a subsidiary of BUPA, owns and runs Beacon Edge Nursing Home. Beacon Edge was originally a private house that has been altered and adapted for its current use and provides nursing care for 41 residents with dementia and 5 of these may be under 65 years of age. The home is on the outskirts of the market town of Penrith close to residential areas and overlooks the town; it is on local bus routes and is within a mile of local amenities. The resident’s bedrooms and communal areas are on the first and ground floors that residents can reach using a passenger lift. The home has three lounges/ dining areas and a conservatory for residents and a quieter area. The home has a kitchen on site and the home’s laundry goes to another nearby BUPA home to be done. Outside the home has two small car parks for visitors and staff and well kept gardens. There is a sensory garden for residents. Fees payable at the home range from £505.00 to £604.00 a week as at 18th September 2006. There are additional charges for hairdressing, chiropody, newspapers and magazines and personal toiletries. The home makes information about its services available through its service user guide and statement of purpose and these, and CSCI inspection reports, are available in the home. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place on 18th September 2006. The inspector was accompanied by the HSE (Health and Safety Executive) Inspector to assess moving and handling of laundry. The inspectors looked around the home and spoke with the manager, residents and staff members. Moving and handling risk assessments and infection control assessments and procedures were examined. Staff recruitment records, training records, medication handling and records and care plans were examined and a selection of records required by regulation. The provider had supplied information about the home and services, asked for by CSCI (Commission for Social care Inspection), before the inspection took place. Before the visit information was also gathered on the service from records of previous visits, notifications, regulatory activities and complaints, concerns and allegations received. What the service does well: The home is comfortable, clean and staff work hard at promoting a homely and relaxed atmosphere for residents and visitors. Families are encouraged to be involved in the daily life of the home and in supporting residents. The management and staff work hard to try and overcome the space limitations caused by the home not being purpose built, such as the small bathrooms, narrow corridors and poor storage facilities. Staff understand and are aware of the needs of residents and work well with other health care professionals and agencies to get the right support and care for residents with particular needs and problems. Nursing and care staff have a good rapport with residents and work with them as individuals. There is a supportive learning culture in the home with training being well supported and organised for staff. A lot of work has been put into developing social aspects of life for residents and having a range of activities and events that meet the individual needs and capabilities of people. Where a weakness in the service provision is identified by the homes internal quality monitoring or outside bodies they are addressed and managed well to achieve improvement. Management within the home is open and responds well to the inspection process. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Whilst many care plans are thorough and up to date reflections of residents needs there are some that have not been regularly reviewed and changes to nursing and health care needs have not been reassessed promptly. Improvements are needed in the monitoring and recording all resident’s psychological health and well being. Also nutritional screening is not always being done on admission for all residents and weights not consistently monitored thereafter. The home has comprehensive and clear medication policies and procedures for the handling of controlled drugs that must be consistently followed by all nursing staff to promote residents wellbeing. Also to minimise the potential for error all hand-written medicines administration records should be signed, checked for accuracy and dated. Medicines given to residents should be signed for promptly following administration to avoid error and any omissions of medicines should have the reason why clearly recorded on the MAR (Medication Administration Record) chart. The home should make sure its infection control procedures are reviewed to include transporting linen and cleansing procedures for vehicles and equipment used. As part of the review full linen bags stored for collection should be kept off the floor. The manager should follow up the findings and recommendations of the HSE inspection promptly to promote safe working practice. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 7 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. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 8 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 Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose, Service User Guide and terms and conditions of residency provide information to promote making informed choices about living in the home. EVIDENCE: Information on the services the home provides is available in the statement of purpose and service users guide. These are provided for all residents and families. The home has updated the information it provides to include the full range of services and support it gives to residents with dementia. Copies of residents/ social services contracts are kept on file by the home administrator and include written terms and conditions. Individual care plans show that new residents needs are assessed before and at admission to the home and individual and ongoing care plans developed from this. The home manager or senior staff do an individual assessment of needs for prospective residents in addition to social services management plans. Information from other agencies, such as mental health, is obtained to try to ensure that the home will be able to meet residents’ needs when they come to live there. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 10 Where appropriate families, other specialised care agencies and professionals are involved in providing information assessments/ management plans of the health and personal needs to be met. Many residents are often unable to express their own thoughts and feelings on specific needs and so information is gathered from as many sources as are available especially on social needs where some families have been very involved. Time is spent helping residents settle in and feel at home and with one resident this was making sure their personal belongings and familiar items were in their room ready for their arrival. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is care planning and assessment system in place to provide information for staff to meet resident’s individual health, personal and social care needs. EVIDENCE: All residents have an individual plan of care including clinical risk assessments and information for staff on meeting resident’s health, personal and social care needs. Some care plans and risk assessments were thorough and up to date but a small number examined have not been completed or regularly reviewed by the named nurse. As a result not all provide a clear and up to date picture of resident’s individual and changing health care needs. This was particularly evident for one resident who had no nutritional or psychological assessments in place. Their care plan indicates challenging behaviour but this is not being regularly reviewed or monitored by the nursing staff responsible. The resident, is taking medicine with potential side affects, including increasing the potential to cause a fall, this is not being monitored. Medication records of non administration and daily records show some affects from this medication on the resident but no changes have been made to the care management plan or falls risk assessment to safely manage the use of this medication. Weights are Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 12 not being consistently taken and one plan says “scales broken” from February to June under the weight section. Working scales are now in place. However, staff do display knowledge of residents as individuals and their needs. Referrals to doctors and other health care and specialised services are being done and working relationships with other agencies are good. This good working relationship is evident for one resident with particular needs as a result of their condition. The home working, with the PCT (Primary Care Trust), has helped this person reintegrate socially. Staff are given medication management training and audits are done on medication systems, as part of quality assurance and storage is good, however some medication records are not in good order. The quantities of a pain relieving medicine were incorrectly recorded in the controlled drugs register. Staff recording the controlled drug did not follow the homes own procedures on recording controlled medication and on reporting errors, reflecting poor professional practice. The manager investigated this error during the visit and obtained confirmation from the pharmacist that quantities dispensed and held as stock were correct and the resident’s safety had not been put at risk. Appropriate action is being taken by the manager with the staff member to address poor practice. The majority of medication charts are in good order but some hand written additions have not been checked, signed and dated by another staff member for accuracy. One person had their medication signed as given but this is still in the monitored dose system (MDS), another medication dose has not been given but no reason for the omission is recorded. Observation during the inspection suggested that resident’s were treated very much as individuals, their dignity, independence and choice promoted when being assisted by staff. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A varied and nutritious menu is provided and a varied programme of organised activities is in place taking into account resident’s individual preferences, choices, capabilities and cultural and religious expectations. EVIDENCE: The home has 3 activities coordinators in post and they have developed a broad, varied and resident centred programme of musical, craft and social events as well as individual and group activities. Information on this aspect of care has been obtained from the Alzheimer’s Society and the coordinators have links with the organisation. Links are in place with local churches to give access to different religious needs and so offer a variety of religious services and pastoral support. The activities team records what works well for individuals and works with families to include them in events. A ‘family meeting’ is due which allows families to raise issues and ideas and take part in a relaxed social event. Resident’s former and current interests are recorded and informative ‘life maps’ inform individual plans and capabilities. The home has ‘memory boxes’ outside all resident’s rooms for them to fill with items that have significance for them and that portray their individuality and life experiences. Care plan risk assessments show that residents are supported to do as they prefer whilst minimising identified risks to their safety. Residents say they Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 14 have enjoyed the regular visits from an ice cream van in the hot weather and being able to buy ice creams themselves. Some residents go out with their families; one has a support worker that takes them out. The home promotes good links with the local community and takes part in “Community Spirit Week” that aims to give opportunities to people who suffer from social isolation. Previously they have done this with the Salvation Army. Two residents were recently invited to a local school musical event and others have made use of a local ‘open gardens’ scheme. Menus indicate a choice of food that is wholesome and varied. Lunchtime was observed to be a relaxed and calm time with staff assisting residents in the dining areas and lounges. The meal was well presented and took into account particular needs for special and softer diets. When observing and overhearing staff assisting residents they are patient and supportive and dealt with occasional unpredictable behaviour calmly. The kitchen has had a new grill fitted and a hot trolley to improve cooking facilities and keep food hot for residents. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaint procedure and tracking system that is followed to make sure complaints are dealt with promptly. Adult protection procedures and staff training help safeguard residents from abuse EVIDENCE: The home has a satisfactory complaint procedure, displayed and made available in the home. There is a thorough complaint logging system that records complaints received and details of the investigation, outcomes and actions taken. This is in good order and provides clear details of investigations and the outcomes of complaints. Complaints monitoring is linked to the home’s quality assurance system to identify any areas of weakness. Information on advocacy and individual rights is available in the home and there are arrangements in place to get this service should anyone need it. Staff have training on dealing with aggression, challenging behaviour and recognising and responding to abuse. The home has procedures in place to protect vulnerable adults and for whistle blowing including multi agency guidance. Where necessary the home has followed multi agency procedures on protecting vulnerable adults to protect an individual’s safety and welfare. The home’s administrator keeps all records of financial transactions and resident’s families are invoiced for additional items. Individual service users have records of their personal monies kept on computer and these go out monthly to show any financial changes. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well decorated and maintained providing a clean, safe and comfortable environment for residents to live in with the equipment they need to promote mobility and physical independence. EVIDENCE: There is regular, planned maintenance of the home and grounds. There are up to date maintenance records for the testing of emergency equipment, call bells, boilers, pumps and water temperatures. The home is well decorated throughout and provides a clean, tidy and homely environment for residents. Some bedrooms have been redecorated and new soft furnishings provided as well as some new dining furniture and kitchen equipment. A former bathroom has been converted into a shower room that is easier for residents to use. There is plenty of communal space and a quieter room if residents want this. This quieter room has been used for family celebrations but two recent hundred birthday parties have been in the main lounges at family’s request to include everyone. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 17 Many residents have their own possessions in their bedrooms making them more personal and familiar for them. The home’s laundry is done at a nearby BUPA home and this is working well. The home has comprehensive infection control procedures and applies universal infection control precautions including the use of protective equipment, the cleaning of equipment and when handling linen. However there are no specific procedures for storing and transporting the linen for washing and cleansing procedures for vehicles and equipment used. There are adaptations and equipment in the home to help residents make the most of their physical independence and to get about the home safely. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of nursing and care staff on duty and on duty rotas are adequate to be able to meet resident’s needs. Training and recruitment procedures promote resident’s safety. EVIDENCE: Staff rotas, training records and observations during the visit show that the home has an appropriately trained staff group providing continuity of care for residents. The rotas show there are enough staff with appropriate skills to provide nursing and personal care during the day and night. However, due to unexpected absences by some staff, there have been times recently when staff levels have been reduced. Rotas show and staff confirm that agency staff are being used in small numbers and there have been occasional times when agency have been unavailable. Speaking to staff it was felt that at such times staff have “pulled together” to cover shifts and provide good care. The manager has covered shifts at short notice herself to maintain the service. The home is addressing this problem in the longer term through internal sickness monitoring processes, starting more overseas staff and holding recruitment open days locally to attract new staff. The manager keeps CSCI informed of staff levels and how any problems are being managed. Training is well organised and resourced and staff have individual training records and profiles to support development and identify needs. NVQ training is well established with a good percentage of staff having achieved this. Records show supervision is being done with staff and recorded in individual Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 19 files. Staff spoken with felt that the manager “worked with them” and supported them in their training and roles. The home is currently introducing individual ‘Learning Portfolios’ for all staff to help plan and develop their learning and practice development and use this alongside the NVQ training to provide evidence of competence. A sample of staff files for most recent staff show thorough recruitment procedures in operation, based on equal opportunities, and checks in place to safeguard residents. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of resident’s health, safety and welfare. EVIDENCE: The manager is experienced, qualified and communicates a clear sense of direction to staff relatives and residents. Resident’s families and friends are asked for their views and opinions using regular surveys, which are collated, and the results acted upon to affect the way the service is run. For example the third activities coordinator was taken on to help extend and develop this part of the service as a result of suggestions from the last satisfaction survey. Relatives can attend regular meetings if they choose to; one is taking place a few days. These allow a relaxed situation for talking with and discussing issues with staff and these are seen as social events in the home for residents and their families. The home has a clear overall organisational development plan that includes the home. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 21 Policies and procedures are reviewed centrally and internal audits are being done to monitor quality. A recent care plan audit has identified the areas of weakness to be addressed and an action plan prepared. The home’s administrator handles the payment of fees and residents money, with their permission or their families’ involvement. Transactions are recorded and kept on computer and receipts sent out for all transactions. Records of maintenance indicate that the home has clear maintenance systems, fire training and servicing and testing practices to promote resident health and safety. There was evidence that appropriate testing and servicing of equipment is being carried out and that the home did Legionella and water temperature testing. The Health and Safety Inspector carried out a separate check on moving and handling risk assessments for the staff moving laundry and, advised and made recommendations on areas that needed attention under the relevant legislation. Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 22 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 2 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 3 3 X 3 3 X 2 Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12 (1) Requirement All care plans must be regularly reviewed and nursing and health care needs, including medication risks, must be reassessed promptly and changes detailed in care plans to reflect changing needs. All resident’s psychological health and well being must be monitored regularly and preventative actions taken. Nutritional screening must be undertaken on admission for all residents, weight monitored, reviewed and a record maintained. The registered person must make sure that policies and procedures for the handling and recording of controlled drugs are understood and followed by all nursing staff. Timescale for action 30/10/06 2. OP8 13 (1) (b) 30/10/06 3. OP8 4. OP9 14 (1) (a) (2) 17 (1) (a) Schedule 3 17(1)(a), Schedule 3(2) 30/10/06 30/10/06 Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 24 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. 3. 4. Refer to Standard OP9 OP9 OP9 OP26 Good Practice Recommendations The registered person should ensure that all hand-written medicines administration records are signed, checked for accuracy and dated. All medicines given to residents should be signed for promptly following administration. Any omissions of medicines should have the reason why clearly recorded on the MAR. The home should make sure its infection control procedures include transporting linen and cleansing procedures for vehicles and any equipment used. When storing full linen bags for collection they should be kept off the floor. The manager should follow up the findings and recommendations of the HSE inspection promptly. 5. 6. OP26 OP38 Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beacon Edge Nursing Home DS0000010094.V304742.R01.S.doc Version 5.2 Page 26 - 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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