Inspection on 20/07/05 for Beacon Edge Nursing Home

This inspection was carried out on 20th July 2005.

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 Edge Nursing Home 09/11/09

Beacon Edge Nursing Home 04/12/07

Beacon Edge Nursing Home 18/09/06

Beacon Edge Nursing Home 22/11/05

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 20th July 2005 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 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 F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beacon Edge Nursing Home Address Beacon Edge Penrith Cumbria Ca11 8BN 01768 866885 01768 899044 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Kathleen Mary Jane Dean Care Home 41 Category(ies) of DE(E) - Dementia, over 65 registration, with number DE - Dementia of places Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 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 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 25 January 2005 Brief Description of the Service: Care First Care Homes Limited, a subsidiary of BUPA, owns and runs Beacon Edge Nursing Home. Beacon Edge is on the outskirts of the market town of Penrith close to residential areas; it is on bus routes and is within a mile of local amenities. It 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 two floors that residents can reach by a passenger lift. The home has three lounges/ dining areas and a conservatory for residents. The home has a kitchen on site and laundry is taken to another nearby home to be done. Outside the home has two small car parks for visitors and staff and well kept gardens. There was a sensory garden for service users. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was on 2oth July 2005. Time during the morning was spent looking around the home, talking with residents in the lounges and as they moved around the home, speaking to the staff, the manager and the senior nurse on duty and also looking at care plans, medicine records, records required by regulation and documentation. Policies and procedures and records were looked at in the afternoon. What the service does well: The home provided a comfortable, well furnished, homely atmosphere for residents and visitors and promoted family involvement in the life of the home. Management and staff worked hard to overcome the limitations caused by the home not being purpose built, such as the small bathrooms. Staff were aware of the needs of residents and worked well with relevant health care professionals to maintain an appropriate service for residents. The staff and management planned ahead well to meet the particular needs of some residents and to make sure the right personnel were in place if one to one support was needed. Throughout the day the inspector saw that staff and residents got on well together, that residents were treated as individuals, and that they were treated respectfully with situations handled sensitively Care plans are detailed and have an emphasis on the individual resident and their choices and preferences and were clear and up to date. The home promoted a learning culture evident in the support given to staff to undertake further and specialised training and to analyze and learn from their mistakes. The staff on duty at the inspection responded positively to the inspection process. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 and 5 Residents and their families had information about the home and services available before admission so they could make an informed choice. A detailed assessment and care planning system and information from other agencies was in place to provide staff with the information they need to meet the resident’s needs when they come into the home. EVIDENCE: Information was available about the home for prospective residents and their families in the statement of purpose and service users guide so they knew what services the home could provide for them. These were provided for all residents. The home should make sure its information includes the range of specific services and support it gives to residents with dementia. Individual care plans showed that new residents needs had been assessed in detail before and following admission and their individual care plans developed from this. Additional staff training to meet the assessed needs had been done before admission. The home manager or senior staff did an individual Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 9 assessment of needs in addition to social services management plans and/or other agencies to ensure that the home could meet them before residents came to live there. Where appropriate other specialised care agencies and professionals were involved in providing information and making assessments/ management plans of the needs to be met. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The care planning and assessment systems in place provides staff with the information they need to satisfactorily meet resident’s individual health, personal and social care needs on admission. The systems for the administration and recording of medicines are satisfactory to meet resident’s medication needs. Personal support was being offered in a way that promoted and protected resident’s dignity and independence. EVIDENCE: All the residents have an individual plan of care setting out their health, personal and social care needs for staff to follow. Any changes identified at the evaluation of care had been put into care plans and needs assessments to give an up to date picture of needs and preferences. The care plans were resident focused emphasising individuality. There was evidence of prompt referral to health care and specialised services and good working relationships with other agencies. Records were kept of the actions taken following their involvement. The home worked closely with other services and on some innovative support projects for residents and their particular needs as a result of their dementia. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 11 Medication procedures and records suggested that resident’s needs are being monitored and met. A recent medication incident had been investigated and actions taken by the home to implement new checking systems to minimise the risk of errors and retraining and raising staff awareness about what they did wrong. Observation during the inspection suggested that resident’s dignity was being maintained when receiving care and being assisted and independence and choice was being promoted. Staff approaches to residents were observed and seen to be friendly and supportive. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14 A programme of organised activities was provided but this was reduced for residents at present due to the lack of a activities coordinator. Contacts with family, friends and the local community were being promoted and maintained according to recorded wishes and abilities. . EVIDENCE: The home was without an activities coordinator due to long term sickness. Interviews had been held the day before and an appointment to the job was expected following satisfactory checks. Staff had been providing what one to one activities and support they could during the interval, with music and groups still continuing and reminiscence sessions. During this time relatives had been encouraged to be more involved in activities with staff. Resident’s former hobbies and interests and ‘life maps’ were recorded and individual abilities and capabilities were recorded. Relatives and families had been involved in social events and at regular meetings that were used as social events. Care plan risk assessments suggested that residents were supported to do as they preferred whilst minimising risks to their safety and arrangements for advocacy were in place. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 13 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 standard(s) 16 and 18 The home has a satisfactory complaint reporting and tracking system that was being followed to make sure complaints were dealt with promptly. Staff were aware of adult protection processes, the procedures in place to protect residents and had received training on this to safeguard residents from abuse. EVIDENCE: The home had a clear complaint procedure, displayed and made available throughout the home. There is a complaints logging system that records all complaints received and the details of the investigation its outcomes and the actions taken and is linked to the home’s quality assurance system. Complaints had been dealt with quickly and records kept of all complaints. Information on advocacy was provided in the home and there were arrangements in place to get this for anyone who required the service. Staff records showed that training had been given on dealing with aggression and recognising and responding to abuse and that further training on challenging behaviour was due. There were procedures in place to protect vulnerable adults and for whistle blowing including multi agency guidance. The home had procedures in place for dealing with verbal and physical aggression. The home’s administrator kept all records of financial transactions on computer that was password protected. Individual service users had records of their personal monies kept on computer and these were sent out monthly to show any financial changes over the month. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The decoration in the home was of an adequate standard, with evidence of regular maintenance. The home provided a clean and homely environment for residents to live in and had the equipment they need to promote mobility and independence. EVIDENCE: The home is maintained with regular, planned maintenance with an adequate standard of decoration throughout that provides a clean, tidy and homely environment for residents. The lounge and dining areas were comfortable and well furnished with good lighting. Outside the gardens are attractive, well kept and have seating for residents. Residents used the garden in the summer months and for the home’s fete. Resident’s bedrooms seen by the inspector had acceptable decoration and furnishings with nursing beds according to assessment of individual need. Many residents their own possessions and this made their bedrooms more personal and homely for them. Some furniture in bedrooms looked worn and Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 15 there was some slight damage. There was evidence that new bedroom furniture was included in the budget for the year and this should be done as soon as possible to improve the environment for residents. The home’s laundry was done at a nearby home and there had been positive feedback on this new arrangement from relatives. Some bathrooms in use are small and make a difficult working environment for staff to assist residents with bathing especially when using equipment. There was evidence that one bathroom was due to have a shower fitted to ease this and was budgeted for. The shower should be put in as soon as possible to improve bathing facilities for residents and improve their experience of bathing. There are adaptations in the home to help residents make the most of their independence and to get about the home safely. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 After a period of change in staffing there is now a satisfactory level of suitably trained and competent staff offering consistency of care to residents. The procedures for the recruitment of staff are satisfactory and offer protection to people living in the home. EVIDENCE: Staff rotas and observation during the visit suggested that the home now had a stable staff group providing continuity of care for residents. The rotas showed there are enough staff on duty to provide adequate nursing and care during the day and night. Staff spoken with enjoyed their work and morale was good Training was well supported and staff received induction and foundation training. Staff had a good programme of on going training covering a range of relevant topics for the resident group including challenging behaviour, aggression abuse and dementia awareness. Two staff members were going on a specialised dementia care training course in order to provide one to one care for a prospective resident who was being helped to re integrate into the community. This was a project working with the NHS. Staff are being encouraged to develop their careers and support is given for training such as NVQ level two and three in care. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 17 The correct recruitment and selection procedures of recently appointed staff had been followed and registration checks on registered nursing staff. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 The manager is well supported by senior staff in providing clear leadership, supervision and planning in the home and this is communicated to residents, families and staff. Systems for resident consultation and involvement are effective and quality monitoring systems and reviews are in place to promote residents interests. Procedures and systems are in place to help safeguard resident’s financial interests and promote their health, safety and welfare. EVIDENCE: The manager and head of care are experienced and very motivated and were seen talking with and observing residents making sure they were content and safe. Conversations with staff and the management team demonstrated a commitment to the health and well being of the residents portraying a caring ethos. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 19 Staff confirmed that formal and daily supervision was in progress and regular staff meetings allowed staff feedback as well as internal reviews of policies and procedures, audits and information sharing. Resident’s families and friends are asked for their views and opinions and these were acted upon to affect the way the service is run. Satisfaction surveys were in use, the results had been published and analysed to monitor improvements. Relatives attended regular meetings to meet and discuss issues with staff and were also seen as social events in the home for residents and their families. The home’s administrator handled the payment of fees and any service user spending monies, with their permission or their families. Transactions were documented and kept on computer and receipts given. Records looked at were up to date and in good order. Records and servicing contracts indicated that the home had systems, training and practices to promote resident health and safety. There was evidence that appropriate testing and cleaning was being carried out but the home should make sure Legionella and water testing records were always fully completed. Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 3 3 Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. 3. 4. Refer to Standard OP24 OP21 OP38 OP1 Good Practice Recommendations Worn and damaged bedroom furniture should be replaced as soon as possible. The planned new shower should be fitted as soon as possible. Records of water testing should always be complete. Information given to residents and families should show the range of services it can offer specifically for dementia care Beacon Edge Nursing Home F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 22 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 F58 F10 s10094 beacon edge v234430 200705 ui stage 4.doc Version 1.40 Page 23 - 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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