Inspection on 22/11/05 for Beacon Edge Nursing Home

This inspection was carried out on 22nd November 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 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 22nd November 2005 1.00 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.V259625.R01.S.doc Version 5.0 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.V259625.R01.S.doc Version 5.0 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 BUPA Care Homes 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.V259625.R01.S.doc Version 5.0 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. 20th July 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 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 DS0000010094.V259625.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 22 November 2005. Time was spent looking around the home, observing residents activities and talking with them in the lounges and as they moved around the home. Care plans, policies and procedures and records required by regulation and documentation were looked at. What the service does well: What has improved since the last inspection? Water tests are now always fully recorded when completed. The home has been up dating and improving the environment for residents by painting and decorating bedrooms and replacing soft furnishings, painting corridors, replacing fire doors and smoke seals. Two new nursing beds have been bought for residents who need them and 2 air mattresses and pressure relieving cushions to improve pressure area care. The use of memory boxes allows residents to display images and items that matter to them and reflect their individuality. A new high-level grill has been bought for the kitchen to improve catering facilities for residents Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 Page 6 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 DS0000010094.V259625.R01.S.doc Version 5.0 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 Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 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 the following standard(s): 1,3 and 4 Information about the home and services is available to residents and families before admission so they could make an informed choice. An assessment and care planning system is in place and information from other agencies was to provide staff with the information they need to meet resident’s needs when they come into the home. EVIDENCE: Information on the services the home provides was available in the statement of purpose and service users guide. These are provided for all residents and families. The home is updating the information on the range of specific services and support it gives to residents with dementia. Individual care plans show that new residents needs are assessed in before and at admission and individual care plans developed from this. The home manager or senior staff does an individual assessment of needs for prospective residents in addition to social services management plans. Information from other agencies is obtained to ensure that the home will be able to meet residents’ needs when they come to live there. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 Page 9 Where appropriate other specialised care agencies and professionals are involved in providing assessments/ management plans of the needs to be met. The home should make sure its information includes the range of specific services and support it gives to residents with dementia. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 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 the following standard(s): 7,8 and 10 There are satisfactory care planning and assessment systems in place. Staff have the information they need to meet resident’s individual health, personal and social care needs on admission to the home. Personal support and care is offered in a way that promotes and protects resident’s dignity and independence. EVIDENCE: All residents have an individual plan of care setting out health, personal and social care needs for staff to follow. The changes in individual needs or care objectives identified at the monthly evaluation of care had been transferred into the care plans and needs assessments to give an up to date picture of needs and preferences. Referrals to doctors and other health care and specialised services were prompt and working relationships with other agencies were good. Records are kept of the actions needed and taken following their involvement. The home has worked closely with other services and on a support project for one residents and their particular needs as a result of their condition. The manager had recently carried out a medication audit highlighting areas for staff to be aware of in their practice. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 Page 11 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.V259625.R01.S.doc Version 5.0 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 the following standard(s): 12 and 15 There is a programme of organised activities taking into account the individual capabilities and preferences of residents. Contacts with family, friends and the local community are promoted and maintained according to recorded wishes. EVIDENCE: The home has two social activities staff that organised and support residents in individual and group social and recreational activities with musical events, slide shows and reminiscence sessions. Staff also provide some one to one support during the day and relatives are encouraged to be involved in activities. A varied programme of Christmas activities is planned that includes relatives. There are regular meetings for families and residents that were used as social events. Resident’s former and current interests are recorded and ‘life maps’ and individual abilities and capabilities recorded. The home has been putting up ‘memory boxes’ outside resident’s rooms for them to fill with items that have significance for them and portrays their individuality and lives. Care plan risk assessments show that residents are supported to do as they prefer whilst minimising identified risks to their safety. Some residents go out Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 Page 13 with their families, one went home for a weekend recently and another has a support worker that takes them out. Arrangements for advocacy are in place if needed or asked for. The home has a varied menu offering a choice of nutritious food. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The home has a complaint procedure and tracking system that is followed to make sure complaints are dealt with promptly. Adult protection procedures are in place to protect residents and staff have been given training on this to help safeguard residents from abuse EVIDENCE: The home has a satisfactory complaint procedure, displayed and made available in the home. There is a complaint logging system that records complaints received and details of the investigation, outcomes and actions taken. Complaints monitoring is linked to the home’s quality assurance system. Complaints had been dealt with quickly and records kept of all complaints. Information on advocacy and individual rights is available in the home and there are arrangements in place to get this service for anyone needing it. Staff are given training had been given 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. The home had procedures in place for dealing with verbal and physical aggression. The home’s administrator keeps all records of financial transactions on computer that is password protected. 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.V259625.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25 and 26 The decoration in the home is of an adequate standard, with evidence of regular maintenance. The home provided a clean and comfortable environment for residents to live in and the equipment needed to promote mobility and independence is available. EVIDENCE: There is regular, planned maintenance of the home and grounds. There are up to date maintenance records of testing emergency equipment, call bells, boilers, pumps and water temperatures. There is an adequate standard of decoration throughout that provides a clean, tidy and homely environment for residents. Corridors have been recently painted and some bedrooms have been redecorated and new soft furnishings provided. Two new nursing beds have been provided and air mattresses. Many residents have their own possessions in their bedrooms making them more personal and homely for them. Some worn and damaged bedroom furniture was due to be replaced with new furniture on order. The home’s laundry is done at a nearby home and this new arrangement is working well. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 Page 16 Some bathrooms in the home are small and make a difficult working environment for staff to help residents with bathing especially when using equipment. One bathroom is due to have a shower fitted to ease the space problem and improve facilities for residents. There are adaptations and equipment in the home to help residents make the most of their independence and to get about the home safely. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The numbers and skill mix of nursing and care staff on duty during the visit, and on duty rotas are adequate to be able to meet resident’s needs. . EVIDENCE: Staff rotas and observation during the visit showed that the home has a more stable staff group providing continuity of care for residents. The rotas showed there are enough staff on duty with appropriate skills to provide adequate nursing and personal care during the day and night. Overseas staff where English is not their first language have been able to attend English classes for literacy skills at level 1 to help them integrate into the team. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 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 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): 31, 32 and 35 The manager provides clear leadership, supervision and planning in the home and this is communicated to staff. 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 motivated and communicate well with staff and residents. 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. 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 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. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 Page 19 Records looked at that are required by regulation are up to date and in good order. Records of maintenance 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 and that the home did Legionella and water testing. Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X X X Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 Page 21 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 OP1 Good Practice Recommendations Information given to residents and families should show the range of services it can offer specifically for dementia care Beacon Edge Nursing Home DS0000010094.V259625.R01.S.doc Version 5.0 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 DS0000010094.V259625.R01.S.doc Version 5.0 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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