Inspection on 01/08/06 for Beacon House

This inspection was carried out on 1st August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beacon House 27/10/08

Beacon House 07/12/07

Beacon House 13/06/07

Beacon House 23/01/06

Beacon House 02/02/05

Beacon House 17/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Beacon House Victoria Hill Road Fleet Hampshire GU51 4LG Lead Inspector Mr Ian Craig Unannounced Inspection 1st August 2006 10:15 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 House DS0000011539.V300685.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 House DS0000011539.V300685.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beacon House Address Victoria Hill Road Fleet Hampshire GU51 4LG 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) 01252 615035 JanetDeavilleN@aol.com Wilton Rest Homes Limited Ms J. Deaville Care Home 20 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (20) of places Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Beacon House is a care home providing care and accommodation for 20 older people, two of whom may have dementia, and is owned by Wilton Rest Homes Ltd, which is a private organisation. The home is located on the outskirts of Fleet and is within access of local shops and other amenities. The home has a large garden maintained to a high standard with seating provided that is accessible to the service users. The home’s fees range from £475.00 to £575.00 per week. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately 5.5 hours. Several residents were either interviewed or spoken to during the visit. One relative of a resident also gave her views about the home. Residents returned four ‘Comment Cards’; these gave views on the service provided. Care staff were also spoken to and/or interviewed. Documents, care records, as well as policies and procedures were examined. What the service does well: What has improved since the last inspection? The home continues to maintain and refurbish the environment. An approved and externally verified staff induction programme has been introduced. Improvements have been made to the process of recruiting staff and staff levels have been increased. An induction programme for newly appointed staff has been introduced. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 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 House DS0000011539.V300685.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements are needed to ensue that each resident is given key information about the home, and, that, the home has a clearer system of ensuring that only those whose needs can be met are accommodated. EVIDENCE: The home has a Statement of Purpose and a Service Users’ Guide, which give clear information about the service provided by the home, including the complaints procedure. The availability of theses documents to residents could not be confirmed. One resident stated that he/she had never been provided with either of these documents and was unaware that inspection reports are available. Neither the Statement of Purpose nor the Service Users’ Guide refer to inspection reports being available. The home promotes prospective residents and their relatives visiting the home to check if it will meet their needs. A visiting relative described how she had been made to feel welcome when looking around the home for the first time and the inspector observed a prospective resident’s relative being shown Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 9 around the home. Several residents stated that they were able to visit before deciding if they wanted to live in the home. The home was not able to demonstrate that prospective residents’ needs are being assessed prior to admission, in order that the home only admits those whose needs it can meet. A resident and a relative were not aware of an assessment taking place prior to admission. Another resident stated that this occurred immediately following admission, and this was backed up by one of the assessment records. Assessments of need were recorded and were generally of a good standard with the exception that they were neither dated nor signed by the person completing them. There was no evidence of the resident agreeing to the assessment. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 the service. Whilst residents’ health and personal care needs are met, this is not always reflected in the care plans, which also fail to include important social needs. Improvements to the policies and procedures for administering and disposing of medication would better protect residents. Residents are treated with respect and dignity. EVIDENCE: Care records were examined for 4 residents. Care plans were available for 3 of these people. The manager could not locate the remaining care records. Assessments of need and care plans are completed using a pro forma. These included details of health and social care needs. None of the care plans were dated or signed by the person completing them and there was no evidence of the respective resident being involved in the process. One resident stated that he/she was never involved in devising a care plan and the inspector discussed with the manager the importance of agreeing care plans with individual residents particularly where the resident has specific social needs and requests. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 11 Daily care records are recorded and a signature entered by the person completing them. These showed that health needs are addressed and that there is liaison with health professional such as general practitioners, district nurses, chiropodists etc. For one person, these records detailed ongoing liaison and joint working with the district nursing team regarding the prevention of pressure sores, but did not include care plan details for staff to follow. The home completes a risk assessment pro forma for each person detailing individual factors and how risk is minimised. These were not available for two of the four residents whose care records were being examined. Medication procedures were examined. Records and stocks of medication showed that residents’ medication was being administered as prescribed. The home’s written policy on the safekeeping, administration, storage and disposal of medication needs to be amended to include the following: • Correct procedures for the disposal and when medication is discontinued. • Procedures for the storage, handling, recording and administration of controlled medication included medications, which must be stored as a controlled drug. It was strongly advised that the home obtains a copy of the Royal Pharmaceutical Society Guidelines on Medicines in Care Homes. Residents and relatives’ of residents reported that care staff treat them with respect and dignity and that heir privacy is promoted. Staff were described as kind, and the inspector observed staff talking to residents in a polite and courteous manner. Each bedroom has a privacy lock. Several residents have their own telephone in their bedroom. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 excellent. This judgement has been made using available evidence including a visit to the service. Residents are provided with stimulation and activities as well as being able to pursue their own interests. There are links with the local community and residents are able to exercise choice in their lives. The provision of food is of a high standard and includes choice from good quality meals. EVIDENCE: Residents were observed reading their own newspapers in one of the lounges. Other residents chose to spend time in their rooms. An activities programme was displayed in one of the lounges giving details of a different activity for each day of the month of August. Notices also gave information about forthcoming trips from the home to local attractions and to the cinema. Residents and relatives confirmed that activities are provided and include cinema trips, entertainment from a visiting singer/musician, etc. Board games, books and magazines are available and the inspector observed staff conducting an activity session with residents in the afternoon. Greater attention is needed in ensuring that individual residents social care needs are highlighted in assessments and care plans, and include the wishes of the person concerned. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 13 A relative of a resident was visiting at the time of the inspection and described how she is always made to feel welcome in the home. There is a visitors’ book in the hall. Residents described how they are able to choose activities, where they eat their meals and that they can suggest activities/improvements etc at the residents’ meetings. There is a choice of meals including a cooked breakfast. One resident was observed having a full cooked English breakfast with toast at 10.30am, which he described as very good. This showed that the home promotes individual preference in the times of eating, as well as the availability of a choice of meals of a very good standard. Residents’ views of the food were varied, with some describing it as of a very good standard and others saying it is variable. One relative of a resident stated that the food is of a very high standard, and that she could not understand why some of the residents made adverse comments about it. Observations were made of the serving of the midday meal and breakfast, and discussions took place with the cook and manager as well with residents and relatives. Residents sit a dining tables set with tablecloths and napkins. Staff bring them a glass of red or white wine if they wish. The midday meal consisted of the following: First course. Choice from melon with strawberry or homemade cream of cauliflower soup or grapefruit. Main course. Braised beef in a wine sauce or home made turkey and mushroom pie, with roast potatoes, broad beans, courgettes with mixed herbs and leeks in cream cheese sauce. Dessert. Home made lemon sponge cake, or ice cream or yoghourt. The inspector tasted both the braised beef and the pie, which were of a very high standard. The menu plans did not reflect the quality and choice provided. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 the service. Improvements are needed to ensure that residents and relatives are aware of the complaints procedure. Residents are protected from abuse. EVIDENCE: The home has a complaints procedure, which is contained in the Statement of Purpose and Service Users’ Guide. A resident and a relative were unsure of the complaints procedure. As several residents were unaware of the Statement of Purpose and Service Users’ Guide, the home needs to take steps to ensure that residents and their representatives are informed of the home’s complaints procedure. The manager explained the system for recording and dealing with complaints. Leaflets promoting awareness of abuse of older persons were on display in the home. Staff receive ‘in house’ training in adult protection procedures, which is verified by an external training agency who provide certificates of achievement for staff. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The physical environment is clean and of a good standard and promotes the dignity and privacy of the residents. EVIDENCE: The home has spacious grounds, which include gardens with places for residents and visitors to sit. A resident was observed enjoying the garden. Several residents commented on how much they enjoy looking out from their bedroom windows onto the garden. The home’s interior is maintained to a good standard and the exterior has been redecorated in the last year. There are two lounges both of which are well decorated and one has oak panelled walls. All bedrooms are single and are of a good size. Each has either an en suite toilet or has access to a nearby toilet. Personal possessions give bedrooms a homely feel. These included furniture, pictures, games, items related to hobbies, etc. Residents’ described how much they liked their bedrooms. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 16 Only one area detracted from a homely feel and this was the siting of a large block of metal staff lockers in a corridor. The home is clean. The laundry has a washer with a sluice programme as well as a drier. Staff have received training in infection control. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 the service. Staff are trained and provided in sufficient numbers to meet the needs of the residents. Residents are protected by the procedures for recruiting new staff. EVIDENCE: The home has improved many aspects of its operation for deploying sufficient staff numbers, induction training for newly appointed staff and recruitment procedures. The home was found to provide sufficient staff numbers. This was evidenced from the staff rota, observation, discussion with the manager, and from the views of residents. Four staff are on duty in the morning with three staff in the late afternoon and evening. At nighttime there is one ‘waking’ staff member and one staff member who ‘sleeps in’ and is available on-call if needed. In addition to the care staff the home employs cooking, cleaning and laundry staff as well as a handyman. Seven of the 16 care staff have attained NVQ level 2 or 3 training, which is just below the minimum 50 national minimum standard. At the time of the inspection none of the staff were due to commence NVQ training, but the manager confirmed that some of the staff will be registering for the course in the near future. One of the staff member’s interviewed described how much she enjoys the work and that she wishes to complete the NVQ qualification. Staff have access to a variety of training courses. Eight staff are undertaking a Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 18 qualification in Dementia Care and records showed that staff have attended courses in moving and handling, first aid, infection control, food hygiene and risk assessment. An induction programme has been introduced for new staff, which is verified by an external agency and meets national standards for social care staff training. Records of induction training were seen and a newly appointed staff member described the process of induction. Recruitment procedures were examined for 3 recently appointed staff. These showed that appropriate checks and references are completed prior to the commencement of work, with the exception that two references had not been obtained for one person. It appeared that the reference had been requested but had not been returned. There was a record that a telephone reference had been obtained but no details were recorded of the content of the verbal telephone reference. Staff confirmed that they completed an application form and attended an interview for the post. Records of interviews were not maintained. A resident had recently been involved in interviewing applicants for care staff posts. This was confirmed with the resident. The inspector viewed this as an example of good practice. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well run, although improvements are needed to ensure it operates in the best interest of residents. Residents’ finances are safeguarded and the health and safety of service users is promoted. EVIDENCE: The manager is completing the NVQ 4 management award. She demonstrated a commitment to improving the service for the benefit of the residents. The home is yet to devise a system of quality assurance based on obtaining the views of residents, relatives, care managers, general practitioners etc., and involving an internal audit and annual development plan. At the moment, the home carries out surveys of residents’ views and there is a monthly visit to the Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 20 home by a representative of the operating company who produces a report. The manager also carries out checks on different aspects of the home’s operation. Residents’ meetings are held and several service users commented on how they are able to raise issues with the home’s management at these meetings. The system of handling and recording any valuables held on behalf of residents was examined and was found to be satisfactory with the exception that a record of valuables was not maintained. The manager agreed to rectify this. Health and safety was also found to be satisfactory. Radiator covers are being installed on a programmed basis to prevent possible burns to residents. Covers have been installed on the more ‘high risk’ radiators. At the time of the visit half of the radiators have been covered and the remaining will be covered in the next year. There is open fire in one of the lounges, which residents enjoy in the wintertime. The manager explained the safe procedures for lighting the fire and for guarding it, and that it has been sanctioned by the fire service. The manager agreed to complete a full risk assessment and plan for the safety of the fire. Staff have received training in relevant health and safety courses, such as first aid, infection control, moving and handling and food hygiene. It was confirmed that at any given time there is at least one staff member on duty who is trained in first aid. Certificates confirmed that equipment is tested and serviced as recommended. The fire logbook showed that fire equipment is tested and maintained. One resident commented that clearer instructions should be made available to residents about what to do in the event of a fire as many were confused about whether to evacuate the building or to remain in their bedroom and await assistance. This should be followed up by the home. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X 3 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 and 5 Requirement Information must be available to residents and their relatives about the home, including details of how a complaint is made and of the availability of inspection reports. Prospective residents needs must be assessed prior to admission to the home. Assessments of need and care plans must be signed and dated by the person completing them. Residents must be consulted and involved in devising their care plans, which must reflect their social needs and wishes. Care plans must include details of assessed risks for each person. Care plans must give details of treatment and prevention of pressure sores as agreed with the district nursing team. The home’s written procedure for the receipt, recording, handling, storage and disposal/discontinuation of medication must be reviewed and updated regarding the DS0000011539.V300685.R01.S.doc Timescale for action 01/11/06 2. 3. 4. OP3 OP7 OP7 14 14 and 15 15 01/10/06 01/10/06 01/10/06 5. OP8 15 01/10/06 6 OP9 13 01/10/06 Beacon House Version 5.2 Page 23 7 OP33 24 following: • Controlled medication, including medication that is stored as a controlled drug • The disposal and discontinuation of medication (this is outstanding from the previous report) A system of quality assurance must be devised and introduced. 01/12/06 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 OP9 Good Practice Recommendations The home should obtain a copy of the Royal Pharmaceutical Guidance for Medicines in Care Homes. Beacon House DS0000011539.V300685.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House DS0000011539.V300685.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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