Inspection on 04/12/07 for Beacon Edge Nursing Home

This inspection was carried out on 4th December 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 Edge Nursing Home 09/11/09

Beacon Edge Nursing Home 18/09/06

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 4th December 2007 10:00 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.V353295.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.V353295.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 210758 deankath@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd 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.V353295.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. 18th September 2006 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 £536.00 to £635.00 a week as at the time of the visit. 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, welcome pack and statement of purpose and these and CSCI inspection reports, are available in the home. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit to Beacon Edge Nursing Home, during which an expert by experience and a pharmacy inspector accompanied us, forms part of a key inspection. It took place over one day and we (The Commission for Social Care Inspection, CSCI) were in the home for five and a half hours. Information about the service was gathered in different ways: • Annual Quality Assurance Assessment document completed by the manager identifying what the service does well and what could be improved. This was returned to CSCI in good time before the visit. • The service history. • Interviews and a report from the expert by experience who was present during the visit. • Interviews with residents and staff on the day of the visit. • Observations made by us in the home during the visit. • Completed questionnaire survey forms from nursing and care staff and people using or coming into contact with the service. We looked at care planning documentation and assessments to ensure the level of care provided met the needs of those living in the home and made a tour of the building to inspect the environmental standards. Staff personnel and training files were examined and a selection of the service’s records required by regulation. The CSCI pharmacist inspector assessed the handling of medicines through inspection of relevant documents, storage and meeting with the manager other staff and residents. The pharmacy inspection took four hours. What the service does well: Feedback from relatives about the service was generally positive. A relative told our expert that, “They work very hard in here to make everyone feel at home and I am very grateful for the care and help they give to us. It feels like a large family. I don’t think it can be an easy job.” Families are encouraged to be involved in the daily life of the home and in supporting residents. There is an excellent programme of activities, the activities co-ordinators are enthusiastic and make every effort to meet the needs of individuals. The varied programme of recreational and social activities is tailored to meet diverse individual abilities and preferences. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 6 The service had good medication records that accurately show the treatment received by residents. Regular quality checks are done to make sure that medicines are handled correctly and safely. The service has care plans for the administration of “when required” sedatives to make sure they are only given if needed. The service has a robust recruitment process to protect residents and gives staff the necessary training and support to do their work What has improved since the last inspection? What they could do better: The service should make sure that medicines it keeps for residents requiring refrigeration are stored at the right temperature. When staff assist someone with their “personal care” they should make it clear in the care notes what level of care they have given not just use a blanket statement so other staff know what has been done and can provide what is still needed. Lighting in communal areas should be sufficiently bright and maintained so all lights are working to promote a safe and light living space for people. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 7 The corridors in the home should be kept free of laundry and equipment to promote a safe and homely environment. The manager should find a permanent solution to the lingering smells of urine that persist on the ground floor. General cleaning should be of a uniformly good standard in all areas of the home to maintain a pleasant environment for residents. 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 Edge Nursing Home DS0000010094.V353295.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.V353295.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service and their representatives have the information they require to make an informed choice about moving in. EVIDENCE: Information on the services the home provides is available in the statement of purpose and service users guide and a comprehensive information pack with photographs and general information. These are provided for all residents and families and a copy is in each resident’s room for reference. The Statement of purpose and service user guide are available in different formats if needed. The home has updated the information it provides in them and states what it aims to provide for dementia and palliative care. The home also has a quarterly newsletter about what is going on in the home. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 10 Copies of residents/ social services contracts are kept on file by the home administrator and include written terms and conditions. The home manager ensures that individual care needs assessments are carried out for each prospective resident. Admissions do not take place without this information. 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 any social services management plans. Information from other agencies, such as mental health professionals, is obtained to try to ensure that the home will be able to meet residents’ needs when they come to live there. 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. Beacon Edge Nursing Home DS0000010094.V353295.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, social and personal care that people receive is based on their individual needs and preferences and they are protected by safe systems for handling medication and regular quality checks. . EVIDENCE: All residents have an individual plan of care and we examined five in detail. These plans had relevant clinical risk assessments including on psychological health and behaviour, nutritional screening and information for staff on meeting resident’s health, personal and social care needs. The service has been working on improving its care planning system to make it a more person focused process that includes, where possible, the individual’s perspective on their care, condition and interests and family expectations. Individual’s care plans include their own comments and what was important to them in daily Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 12 life. This was particularly useful in providing meaningful recreational opportunities for people. The care plans and risk assessments were thorough and up to date and had been regularly reviewed by the named nurse and appropriate changes made. As a result there was 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 a wound assessment and management plan. It would make for better consistency and monitoring if staff recorded exactly what personal care they had helped someone with. It was in some cases hard to tell exactly what level of personal care someone had been given. If someone had a bath, shower or just a wash or other care it should be stated what had been done to assist that person not just “personal care given”. Referrals to doctors and other health care and specialised services are being done and working relationships with other agencies are good. Observation during the inspection suggested that resident’s were treated very much as individuals, their dignity, independence and choice promoted. One person who lives there said, “Well, if they talk to you nicely like that, it can only be good, can’t it?” We looked at the handling of medication and found the service looked after and administered medicines on behalf of the people who lived there and managed this well. Records for the receipt, administration and disposal of medicines were good with only very occasional omissions and clearly showed the treatment received by residents. There was a good system for monitoring the stock level of medicines so they could be accounted for at all times. A sample of medicines was checked and this showed that medicines were handled properly and were given correctly to residents. The service also did regular quality checks to make sure medicines were handled safely. Nursing staff had recently received training in the safe handling of medicines and were assessed as competent in the task so that residents receive their medication in a safe manner. Beacon Edge Nursing Home DS0000010094.V353295.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their lifestyle and are supported to maintain their independence and take part in meaningful recreation suited to their capabilities. The dietary needs of the residents are well catered for. EVIDENCE: The home has 2 activities coordinators in post and they have developed a broad, varied and person centred programme of individual and group based musical, craft and social events and activities. Information on activities is on display in the home and in the home’s newsletter. Resident’s former and current interests are recorded and informative ‘life maps’ inform individual plans and activities. The home has ‘memory boxes’ outside all resident’s rooms for them to fill with items that have significance for them and their families and that portray their individuality and life experiences. Care plan risk assessments show that residents are supported to be independent and to do as they prefer whilst minimising identified risks to their Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 14 safety. A relative told us that they felt residents were not restricted in any way within the home. We spoke with the two activities coordinators and our expert spent time observing them at work. It was evident from speaking with them about their work and how they approached it and looking at their records, life maps and personal resident profiles that they were very positive and enthusiastic about working with and involving the people living there in meaningful activities and recreation. A resident told us that they enjoyed going out for trips on Thursdays and liked the musical entertainment best. The service has a range of musical instruments for people to try and also use as part of the music sessions. Provision is made for people to follow their religious preferences. During the visit the expert by experience was able to spend some time in the lounge/dining areas on the ground floor and observe people engaged in activities. They noted, “The activities co-ordinators are enthusiastic and make every effort to meet the needs of individuals. People who live at Beacon Edge were helping with putting up decorations at the time of the visit and in the afternoon a reminiscence session took place. Several people were participating in the project which involved painting a glass panel and talking about Penrith and surrounding areas - visiting relatives were given the opportunity to join in.” Over the Christmas period, arrangements have been made for school children to visit to sing carols and the Salvation Army will also provide some Christmas music. Musical entertainments have been booked for New Year and a Christmas Variety Show in addition al to usual activities and the ‘coffee club ’meeting. Recently the home has been developing its ‘Living History Project’. This is an initiative to help the people living there to reminisce and incorporate their memories and experiences in a lasting feature in the home. The theme is the 1940’s and 1950’s and relatives and friends are also involved in collecting items. One visitor said, “the home puts a lot of effort into activities, I have seen the organiser arranging games, exercises and entertainers. The activities organisers are excellent”. We saw that mealtimes are well organised and the expert by experience observed that there was good communication and interactions between staff and the people they were assisting. There was a choice of food at each meal and vegetarian and diabetic diets can be catered for. Food looked appetising and well presented although one person asked to have their meal changed and had the second choice of pasta and said, “This food is not what I am used to, it seems to have lumps in it”. Another person said,“The food is nice, they do a good job.” The television was left on in one of the lounges during lunch and this may have been a distraction. The atmosphere in the small lounge was calm and the high staff level ensured that everyone had a good experience throughout the meal. Beacon Edge Nursing Home DS0000010094.V353295.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaint and adult protection procedures are in place and people who use this service are able to express their concerns. Their protection from abuse is being promoted through staff training and using relevant procedures. EVIDENCE: Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 16 The home has a satisfactory complaint procedure, displayed and made available in the home and the information provided to residents and families. There is a complaint logging system that records complaints received and details of the investigation, outcomes and actions taken. This provides clear details of investigations and the outcomes of complaints. The service has recorded 9 complaints made to them in the last 12 months. All concerns raised are reported on regionally and go back to BUPA’s Quality and Compliance Team for overall monitoring nationally. Survey responses indicate relatives are aware of how to make a complaint also residents who responded. One relative felt the complaint process moved slowly in response to niggling issues” they had raised, although the home had dealt with” bigger issues positively”. 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 challenging behaviour, dementia awareness and recognising and responding to abuse. We discussed adult protection with the manager given the challenging behaviour expressed by some residents at times. The manager outlined the service’s training plans to provide more staff education on the importance of reporting and responding to any concerns about care and potential abuse to try to make sure staff recognised its importance in this care environment. They were addressing getting more in house training on recognising abuse. The home has procedures in place to protect vulnerable adults and for whistle blowing including multi agency guidance. When necessary the home has followed multi agency procedures on protecting vulnerable adults to protect an individual’s safety and welfare. They have referred 5 incidents under adult protection procedures to social services for investigation and action in order to protect people living there. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 17 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): NMS 19, 20, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are reasonably well maintained and decorated for the people living there but malodours are detracting from a homely environment. 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. We found that décor is, in the main, attractive and the addition of Christmas decorations added to a cheerful atmosphere. Two of the lounges are spacious and enable people to walk around either with help, unaided or with mobility aids. 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.V353295.R01.S.doc Version 5.2 Page 18 The spread of the use of lounges means that they are not overcrowded and the small lounge in particular has an appealing atmosphere with the added attraction of the extended room attached. We found on entering the home that unfortunately a strong smell of urine was apparent on the ground floor. Throughout the visit this odour did not dissipate and it was noticed that a wet seat was placed against a radiator to dry – which perhaps contributed to the smell. The manager is aware of this problem occurring at times and cleaners did act quickly when a cleaning need occurred. The manager should look at ways of permanently improving this to provide a more pleasant environment for residents, staff and visitors. One relative did comment that “A few air fresheners about the place might make the atmosphere more pleasant” and another that “cleanliness could be improved”. A resident told us that sometimes the toilets were “messy”. We saw that several chairs and settees had missing seat cushions and some others were split and some had miss-matched cushions. The manager explained to us that these were away being cleaned and are due back. There were some cobwebs in the staff office and in the lounges and some carpets looked well worn. These things detracted from the homely environment and should be attended to promptly. Lighting was insufficient in some areas - in one lounge only half the lights were switched on and of those that were, some bulbs were not working. This was of concern in terms of health and safety, overall atmosphere and perhaps prevented people from seeing their food. One ground floor bedroom was particularly poorly served by natural light making it a less pleasant place to be for any occupant. All bedrooms are single occupancy and those we saw had been personalised by residents and relatives to make the space more personal. The home’s laundry is done at a nearby BUPA home and has been 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. There are also specific procedures for storing and transporting the linen for washing and cleansing procedures for vehicles and equipment used. We looked at the storage areas for laundry awaiting collection and these were appropriate. However when we arrived in the morning the home’s laundry was being brought in and this was left in the main corridor running between the main lounges. This cluttered the area and got in people’s way with trolleys and using aids. It was some time before staff had cleared it all away. The manager should find an alternative to this for safety and to keep a homely environment. In discussion with the manager it was evident that the layout of the building does have an effect on the environment. It is not purpose built and some areas are cramped and become cluttered easily. The manager could confirm that under the maintenance plan for next year the home is due for total refurbishment in all areas and that should improve the overall environment for people living there. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 19 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): NMS 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. People using this service are protected by robust recruiting procedures. Trained and experienced staff support and care for the people living there. 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 training and skill mixes to provide nursing and personal care during the day and night. There are registered nurses on duty throughout the day and a senior carer on each shift during the day with 4 health care assistants. There have been times, especially at weekends, when staff levels have dropped due to unexpected sickness and this can affect people’s care. At present permanent staff are covering shortfalls indicated on the rota. A new registered nurse is due to start work following recruitment checks and this should also help staffing pressures. We looked at the staff files and recruitment process for 4 members of staff. These were very well maintained and contained all the necessary checks including Criminal Records Bureau (CRB) checks and references. Induction is carried out for new staff over 3 days. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 20 Staff training is well supported and BUPA has a lot of its own in house training for staff. Staff have their own individual learning portfolios and systems in place to ensure mandatory, refresher and other training is given as needed to maintain skills. NVQ training is well supported and 50 of care staff have NVQ level 2 in care and some have level 3. Staff surveys and indicated and staff told us that they receive the training that they need to do their job and that they had been given induction training before working with residents. Staff told us they enjoyed their work and felt supported by the manager. Relatives and residents made positive comments about the staff in the home. One relative said that “overall the staff are excellent” and another that “on balance I think they do a good job- it is a very stressful job”. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 21 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): NMS 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service live in a home that is safe, well managed and run in their best interests. EVIDENCE: The manager is suitably experienced in this area of care, is qualified and communicates a clear sense of direction to staff, relatives and residents. Staff told us that generally they felt supported by the manager, although some found her more approachable than others. They confirmed that they were given regular supervision and these are recorded and on file. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 22 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. Relatives can attend regular meetings if they choose to and survey responses indicated they found them useful. 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. Policies and procedures are reviewed centrally and internal audits are being done to monitor quality. The manager regularly audits aspects of its service to monitor quality and reports back to the organisations quality and compliance department, making changes if needed. 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. The manager holds regular Health and safety meetings to monitor this and this included staff. . There is evidence that appropriate testing and servicing of equipment is being carried out and water temperature testing done. Staff have been given fire training at appropriate intervals. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X 2 3 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 3 Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 24 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 OP7 Good Practice Recommendations When staff assist someone with their “personal care” they should make it clear in the care notes what level of care they have given not just use a blanket statement so other staff know what has been done and can provide what is still needed. The temperature of the medicines fridge should be monitored and adjusted so that it is appropriate for the storage of medicines. Lighting in communal areas should be sufficiently bright and maintained so all lights are working to promote a safe and light living space. The corridors in the home should be kept free of laundry and equipment to promote a safe and homely environment. The manager should find a permanent solution to the lingering smells of urine that persist on the ground floor to DS0000010094.V353295.R01.S.doc Version 5.2 Page 25 2. OP9 3. 4. 5. OP20 OP22 OP26 Beacon Edge Nursing Home 6. OP26 provide a more pleasant environment for people. General cleaning should be of a uniformly good standard in all areas of the home to maintain a pleasant environment for residents. Beacon Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Edge Nursing Home DS0000010094.V353295.R01.S.doc Version 5.2 Page 27 - 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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