Inspection on 13/06/07 for Beacon House

This inspection was carried out on 13th June 2007.

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 01/08/06

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 Chris Johnson Unannounced Inspection 13th June 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 House DS0000011539.V339074.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.V339074.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 (0), Old age, not falling within any registration, with number other category (0) of places Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: Beacon House is a care home providing care and accommodation for 20 older people of whom may have dementia. The home 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 cost of living at the home ranges from £520 to £650.00 per week. Additional charges are made for hairdressing, chiropody and some activities that require an entrance fee such as the theatre. People are free to have their own phone line installed and are liable for costs incurred such as connection, standing charge and billing. Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards and compliance with regulations. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out on 13th June 2007. During this visit a tour of the premises was completed that included looking at people’s bedrooms and all communal areas of the home. Staff and care records were inspected; staff, people living at the home and the manager were spoken with and staff were observed during their day-to-day interactions with those living at the home. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. The manager completed a self -assessment document prior to the visit. Questionnaires were sent to twelve of the people who live at the home prior to the visit and six were returned. What the service does well: What has improved since the last inspection? Medication practices have improved since the last inspection and this provides greater safeguards to the people living there. Some aspects of care planning, and the assessment process have been improved however further improvement is needed in both areas. The home continues to make improvements to the décor, physical environment and replacement of furnishings as necessary. Beacon House DS0000011539.V339074.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. The summary of this inspection report can be made available in other formats on request. Beacon House DS0000011539.V339074.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.V339074.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 and 6 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes’ assessment process has been improved although further improvements are needed to reduce the risk of someone moving into the home whose needs cannot be met. Amendments are still needed to some of the homes’ written information in order that people have all the necessary information about the home. EVIDENCE: Beacon House does not provide intermediate care. This standard is therefore not applicable and was not assessed. The home provides information to people at the point when they are considering moving into the home. These are in the form of a ‘Statement of Purpose’ and a residents’ handbook also known as a ‘Service User Guide’. The residents’ handbook is well laid out, user friendly and provides lots of information about the home and is available in large print. Some of the Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 9 information in the Statement of Purpose is outdated and amendments are needed to ensure that people have the correct information. This was highlighted at the last inspection but no action had been taken to date to amend this. All people who completed a survey responded that they had been provided with sufficient information about the home to make a choice. Some people commented on the level of information and assistance that they had received when initially visiting home. One relative commented, “All our questions were answered and the information we were given matched exactly to the wonderful service the home provides”. The home encourages people to visit prior to making a decision whether they wish to move in. This was confirmed through feedback from surveys and in discussion with people living at the home. The home has now implemented a pre-admission assessment process and the documentation for this is included in the new care planning system that the home has purchased. Whilst this is an improvement on previous practice and means that people are now assessed before they move in to the home rather than at the point of entry, further improvements are needed. From examination of assessment records it was found that documentation had not been not fully completed in all cases and therefore did not demonstrate that a full assessment had been made. Beacon House DS0000011539.V339074.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some improvement has been made to care planning and medication procedures. However the quality of written information and lack of detail in care plans and written information in general means that the home cannot demonstrate that they have sufficiently considered or are able to meet peoples’ care needs. EVIDENCE: The home had introduced a new care planning system since the last inspection. The care plans of three people were looked at during the site visit. Whilst plans were available for these people they lacked sufficient detail and guidance in some areas of the peoples’ care needs. Care plans did not address all assessed and identified needs or risks and did not provide sufficient detail regarding how some risks were to be managed. There were some contradictions within plans regarding people’s needs and plans did not adequately address people’s social or religious care needs. Written information Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 11 in one person’s care plan did not demonstrate that any value or consideration had been paid to the person’s social or religious care needs. Likewise written information in the same person’s daily notes were inappropriate and would suggest that this person had not been afforded the right to their own freedom of choice. This was brought to the manager’s attention and also this information was passed to the local authority in line with agreed Safeguarding Adults protocol. This would suggest a lack of staff training and also a need for better monitoring of the homes’ written records. Risk assessments were in place for some issues though not all and risk management plans were lacking. However in discussion with members of staff they were all able to demonstrate a good understanding of each persons’ care needs and describe their care needs and any associated support and methods to be used in good detail. It was evident that currently staff retain more information mentally than is written down about the person. A requirement made at the last inspection regarding signing assessments and care plans had been partially although not all had been done. However the inspector was satisfied that this was being actioned. There was also more evidence that people had been consulted about the content of their plans than there had been at the last inspection. People reported that they considered their health care needs to be met and that they had access to a full range of healthcare support and that staff supported them to access appointments as necessary. However from examination of the daily recording notes kept it was noted that there were large gaps of up to eleven days when nothing was recorded for some people despite health issues being identified that needed to be monitored, there was no evidence that any follow up or monitoring of a persons condition had been undertaken. In respect of one person it was found that daily notes were only recorded regarding negative issues. One person’s notes referred to several incidents whereby they had exhibited abusive and aggressive behaviour towards staff. Despite this there was not a risk assessment or risk management plan to address this. Neither was there any guidance for staff. Daily records and care plans when well written, help the home to provide a consistent approach and good quality of care. Detailed daily records would help the manager to audit the care being provided and ensure that staff are following the guidelines in the care plans. Improvements had been made to the homes’ medication procedures since the last inspection and both previous requirements have now been met. The manager has been auditing the administration sheets on a weekly basis. Medicines were suitably stored and all medicines administered had been signed for correctly. The medication administration records of three residents were examined against stock levels and these were found to be accurate. What was noted was that the home had not checked, signed or kept an accurate record of quantities of medication received into the home and this will need to be addressed. Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 12 During the visit to the home it was noticed that some confidential documents relating to individual residents were not kept securely. This was discussed with the manager and she agreed to amend this. In all other respects, privacy, dignity and confidentiality are respected. Everyone contacted as part of this inspection were in agreement with this. In discussion with staff they were able to demonstrate an understanding of the values of privacy and confidentiality. Beacon House DS0000011539.V339074.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): 12,13,14 and 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The meals in this home are good offering both choice and variety. People have the opportunity to take part in a range of activities and are free to spend their time as they choose. Staff shortages and the lack of detail within care plans means that those with higher support needs do not always experience the same outcomes as others. EVIDENCE: The home provides a range of different organised activities and people can choose whether or not to join in with these. This was confirmed through discussion with people living at the home. Records of organised activities from previous months were seen and these showed that people had been provided with the opportunity to take part in quizzes, beauty sessions, croquet, movement to music, indoor golf and other games such as dominoes. Visits to special events the theatre and trips out are also available at different times. People were observed to be free to choose where and how they spent their time. People spoken with told the inspectors that they were free to spend their time as they chose and that there were not any restrictions imposed upon Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 14 them and that they could pursue their own interests. The home recognises that it could provide more one to one activities and some staff reiterated this. The home plans to try to involve more local groups into the home. Staffing levels at times influence the level of one to one activities and this is discussed in the staffing section of this report. The lack of detail within care plans regarding people’s social needs means that the home cannot at present demonstrate that they are meeting all peoples’ needs in this area, particularly those with higher support needs. The home has an open-visiting policy and this is promoted. This was confirmed through examination of the visitors’ book, discussion with people living at the home and responses in surveys. Records were available to demonstrate that the home consults with the people living there and offers them the opportunity to be involved in decision making within the home. This was established from the minutes of ‘resident meetings’ that are held regularly. The organisation has some bungalows situated within the grounds of the home accommodating people with low support needs. These people often attend the resident meetings. The inspectors discussed this with the manager as these people are at present having an influence over decision making within the home although they do not live there. It was agreed that this would be looked at. The previous inspection report highlighted peoples’ satisfaction with the standard and choice of food. There was no evidence to suggest that this had changed. People living at the home and their relatives were complimentary about the food. One person commented, “ Mum says the food is lovely. Individual tastes are addressed and there is always a choice of dishes”. Other comments included; “The food is well presented and a wide variety of menus offered” and “ they make efforts to accommodate particular tastes”. Menu records demonstrated that people are provided with a nutritious, healthy and varied diet with plenty of choice. The inspectors observed lunch to be served in the dining room in a relaxed and unhurried manner. Beacon House DS0000011539.V339074.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): 16 and 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The majority of the people living at this home are aware of their right to make a complaint. All staff require training in adult protection training. EVIDENCE: The home reported that they had not received any complaints within the last twelve months and this was substantiated through examination of the home’s complaints log and feedback from surveys. Neither had the Commission for Social Care Inspection received any complaints about the home. Surveys showed that the majority of people are aware of the home’s complaints procedure. As previously stated the homes’ Statement of Purpose had not been updated and the complaints procedure contained within this document is outdated and needs to be reviewed. In discussion with staff they were aware of their responsibility to pass on any complaints to the manager. The self-assessment document completed by the manager prior to the visit stated that they had made staff more aware of abuse and neglect issues and had provided ongoing training. However staff spoken with had not received adult protection training and there were not any records to demonstrate that training had taken place. This will need to be addressed. In discussion with staff they were able to demonstrate an awareness of the issues and the need to report any concerns that they may have. Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,25 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This home provides a comfortable, clean, well-maintained and homely environment. People living here value the privacy that having their own rooms’ affords them. EVIDENCE: During the visit to the home a tour of the premises took place. This included looking at several peoples’ bedrooms and all communal areas of the home. The home is decorated and maintained to a good standard. It is well furnished, homely, clean and comfortable. Furnishings are replaced regularly and bedrooms are redecorated prior to someone new moving in. People were observed to be free to access all communal areas of the home. The home has spacious grounds, which include gardens with places for people and their visitors to sit. During the visit several people were seen to make use Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 17 of the grounds and garden. People told the inspector that they enjoyed using the garden and grounds. All bedrooms seen were spacious and comfortable and had been personalised with the person’s own furniture and belongings reflecting each persons’ individuality and interests. When asked what they liked about living at the home one person commented, “ I appreciate the fact that I could bring my own things, it makes a difference”. People also commented on the fact that their privacy was respected and that when in their own rooms they were left alone unless they needed or requested assistance. The environment is maintained appropriately and a maintenance person was on site during the visit to carry out repairs and general maintenance as necessary. Good standards of hygiene are maintained throughout the home and infection control procedures were being followed. On the day of the visit the home was found to be very clean and tidy and no unpleasant odours were present. Feedback from relatives and people living at the home reiterated this. Comments included; “ We have always commented on how well the staff keep the home odour free” and “ Mum has a lovely room which is cleaned every day as is her bathroom. The dining room always has clean tablecloths and flowers on the table. It is like going into your own home”. Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff in this home are helpful and caring. Recruitment practices provide safeguards to those living there. Whilst staff consider that they receive a good level of training the lack of training records means that the home cannot demonstrate this to be the case. At times the home is short staffed and this impacts on the people living there especially those with higher needs. EVIDENCE: Staff rotas were examined. On the day of the visit the home was one staff member short day due to unexpected sickness. Currently the home only has one bank worker that they can call on to cover staff shortages and existing staff provide additional cover through working overtime. The home does not use agency staff. The manager and senior staff work alongside care staff as part of the everyday rota. Staff reported that when the home is fully staffed then things work well and they are able to give one to one time to people. The home employs domestic staff as well as care staff and this means that care staff can spend more time attending to peoples’ needs. However the home does need to ensure that there are sufficient levels of care staff on duty at any given time to meet the needs of people living at the home. The manager stated that they were expecting to employ an additional bank worker to assist with staff shortages. Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 19 Staff commented that they received a good level of training. Training records are not currently maintained and so the home cannot demonstrate this to be the case. The manager reported that one staff member was due to commence courses in moving and handling and risk assessment that would qualify them to become an in house trainer. The home employs a total of seventeen part time and full time care staff. Currently less than 50 of staff have completed a NVQ level 2 or above. However the home is striving to improve this. Six additional staff members are working towards the qualification and others were due to enrol. The recruitment files of new members of staff were examined and these demonstrated that the home was following appropriate recruitment procedures, to safeguard people living at the home. Records were also available to demonstrate that new staff followed a suitable induction period. During this period they are supplied with workbooks and induction packs with a range of policies and procedures for them to familiarise. In discussion with staff they were in agreement that they had received enough support and information when new in post. People spoken with or whom returned a comment card commented on the caring attitude of staff. Comments included; “We like the way the staff clearly work as a team, respecting absolute confidentiality at all times. Sometimes one needs to remind them of a particular course of action –not often”, “The Staff are always cheerful and helpful when we visit”, “Staff are caring and cheerful “ and “The staff are helpful and will give me help if I want help”. One person did comment that although the staff always listened they did not always pass information on to colleagues or to senior staff. Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 36,37 and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager of this home is caring, accessible and approachable to the people living there, their relatives and the staff team. Health and safety is promoted. The management of the home is however lacking in some areas. Priority needs to be given to ensure that staff receive better supervision and that the quality and accuracy of written information is monitored. EVIDENCE: Several requirements were made at the last inspection. The manager had taken action to address some of these. Others had been partially met within the agreed timescale and further work is required to ensure that all areas requiring improvement are addressed. In discussion with the manager and from evidence gathered throughout this inspection more management time is Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 21 needed to enable the manager to fully fulfil her role. The manager was in agreement with this and explained that currently she is required to do a lot of administrative work and said that she felt that administrative support was needed. The manager also said that she needed to be able to delegate more tasks and that this would free up her and the other senior staff to concentrate on the management of the home. During the course of this inspection it became evident that several areas of management are lacking. None of the staff had received formal supervision or appraisals. Although staff did comment that they found the manager and senior staff to be approachable and that they could access them easily if they needed support or advice. Some of the home’ records such as the daily recording notes (as discussed in the ‘Health and Personal Care’ section of this report) are poorly maintained and there does not seem to be a system for monitoring the quality of information recorded in care plans etc. Records showed that staff meetings for day care staff had been held on 11/1/07 and 10/5/07. There were not any records to demonstrate that meetings had been held with ancillary staff. No meetings had been held for night care staff at all in 2007. The manager said that she had tried to arrange these but sickness had prevented meetings from taking place. A requirement had been made at the last inspection that the home devise and introduce a quality assurance system. The home had purchased a system although this has yet to be implemented. The manager did demonstrate a caring approach and she is accessible to those living at the home and their relatives/representatives. Comments from people included, “There is always a member of the management team available to help and listen and all staff are always willing to do whatever they can to address concerns” and “As a relative I can always talk to the manager or deputy manager if I need to check something out”. There were not any concerns raised as a result of this inspection regarding the financial viability of the home and it was evident that the proprietor continues to reinvest in the home. Residents’ finances are safeguarded. All monies looked after on residents’ behalves were found to be stored safely and appropriately. All transactions are receipted and a clear audit trail is maintained. Health and safety is within the home is promoted. Examination of the fire logbook demonstrated that regular and thorough testing of the home’s fire detection and fire-fighting equipment was being carried out. Individual risk assessments for each person living at the home had been completed with regard to fire. These were very detailed and provided clear details of each persons’ ability to get out of the building, their reaction time to alarms and their level of understanding and support required. Minutes of ‘resident meetings’ demonstrated that fire safety is discussed with people on a regular basis. Although the manager and staff confirmed that they had received regular fire training there was no record to support this. Certificates and Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 22 service contracts were seen and the inspector was satisfied that all equipment used within the home had been regularly checked and serviced. There were not any concerns with regard to safety within the home environment Beacon House DS0000011539.V339074.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 2 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 X X X 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 1 2 3 Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 24 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 given to all service users both current and prospective must be up to date especially in relation to the Statement of Purpose and how to make a complaint. (This is an amended requirement of 01/08/06) Full assessments must be completed prior to admitting service users and records are to be kept of these. All care plans must be reviewed. They must be more detailed and provide specific support instructions and fully address all assessed and identified needs including the identification of any risks and how these are to be managed. Procedures must be followed for recording of medicines received into the home. All staff must receive adult protection training. Staffing levels must be kept under regular review to make certain that the needs’ of all living at the home can be met. DS0000011539.V339074.R01.S.doc Timescale for action 01/09/07 2. OP3 14 (1) 01/09/07 3 OP7 13 (4) (c) 30/09/07 4 5 6 OP9 OP18 OP27 13 (2) 13 (6) 18 (1) (a) 01/09/07 31/10/07 30/09/07 Beacon House Version 5.2 Page 25 7 OP33 24 8 9 OP36 OP37 18 (2) 17 A system of quality assurance must be implemented. (This is an amended requirement of 01/08/06) A system of formal supervision must be introduced for care staff. All records must be kept up to date. 31/10/07 01/09/07 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beacon House DS0000011539.V339074.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House DS0000011539.V339074.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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