Inspection on 23/01/06 for Beacon House

This inspection was carried out on 23rd January 2006.

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 House 27/10/08

Beacon House 07/12/07

Beacon House 13/06/07

Beacon House 01/08/06

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 Liz Palmer Unannounced Inspection 23rd January 2006 11:00 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.V279241.R01.S.doc Version 5.1 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.V279241.R01.S.doc Version 5.1 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.V279241.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Beacon House is a care home provididing 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. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection for the year 2005/2006 and was unannounced. Any key standards not assessed on this inspection were assessed at the previous inspection. Therefore, this report should be read alongside the previous report. It took place over 3.5 hours. Three residents and three staff were spoken to during the inspection. What the service does well: What has improved since the last inspection? Care plans have improved to ensure consistency of care to residents. Radiator covers have been fitted to high risk radiators. A quality assurance questionnaire has been devised and given out to residents thus taking into consideration their views on improving the home. Improvements have been made to the record keeping of residents’ monies. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 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.V279241.R01.S.doc Version 5.1 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.V279241.R01.S.doc Version 5.1 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): None of these standards were assessed. EVIDENCE: Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 9 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 and 9. Improvements to care plans ensure residents’ changing needs are clear and risks are assessed. Improvements to the policies and procedures for administering and disposing of medication would better protect residents. EVIDENCE: Care plans have been improved as required at the last inspection. The three care plans looked at showed that residents’ individual needs are clearly recorded and regularly reviewed. Risk assessments have been carried out and detail how to minimise the risk identified, for example, for bathing, mobility and eating. Staff review any changes to care plans at the six weekly staff meetings. The home has a clear policy for the ordering, storing and administering of medication. Most medication is on a monitored dosage system provided by a pharmacist. Two people check and administer medication, one of which is a senior who has had training. Two staff were administering medication during the inspection, they appeared to be competent and confident in what they were doing. No residents currently self-administer medication but they have Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 10 the option to do so. This would be risk assessed and a suitable lockable storage would be provided. It was noted that one resident was being administered a dosage different to their prescription. This had been agreed by the general practitioner (GP) but not recorded. A requirement for medication to be administered only as prescribed was made. There is currently no written procedure for the disposal of medication which has been refused or wasted once out of the blister pack. A requirement has been made for the manager to produce and implement a safe procedure for the disposal of all medicines. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 11 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): 14 The home encourages residents to remain independent and have choices in their life. EVIDENCE: Resident’s are supported to be independent in their financial affairs. All current residents’ next of kin has power of attorney and would support them in any legal or financial matters. The three residents spoken to said they valued their independence and felt the home supported them to maintain it. Residents are encouraged to make choices, for example how to spend their time. A restriction to one resident’s freedom of choice was noted. This had been requested by a relative to safeguard the resident concerned. The manager was advised that an assessment should be undertaken to clearly establish the risk and detail the actions being taken. A recommendation has been made. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 12 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): None of these standards were assessed. EVIDENCE: Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 13 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): 25 Plans to cover all radiators based on high risk first protect residents. EVIDENCE: A requirement for high risk radiators to be covered has been met. The home plans to cover four radiators every two months. Half the radiators in the home have been covered already starting with the highest risk ones first. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 14 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 The recruitment of new staff would ensure residents are supported by a suitable number of adequately qualified staff. Improvements to the recruitment procedure would promote the safety of residents. A robust induction programme would ensure that staff are trained and competent. EVIDENCE: The home has been short staffed and is currently waiting for three new staff to start. The existing staff have covered the shortfall so that agency staff were not used. This offers consistency to residents but is not satisfactory long term. Of the 13 care staff currently employed 6 have achieved National Vocational Qualification (NVQ) Level 2 or above. This falls just below the required standard of 50 of care staff being qualified to this level. The manager is planning to meet the standard once new staff are employed. This will be monitored at future inspections. Staff spoken to were competent and confident about their work. Residents said they felt in safe hands with the staff and management of the home. Recruitment procedures were inspected and it was found that although some procedures had been followed, for example, an application form had been filled in and references were taken up. One of the staff files did not have any references and some staff had a criminal record bureau (CRB) check that had been transferred from a previous employer, therefore no protection of vulnerable adults (POVA) check had been carried out. A requirement was made. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 15 The requirement, made at the last two inspections, for the home to provide induction and training based on the Skills for Care guidance, was again discussed with the manager. The requirement has not been met but the manager stated she has an agreement from the owner to buy a suitable package that will comply with the requirement. Staff spoken to had received training in areas such as dementia care, adult protection, food hygiene, first aid, medication and NVQs. Residents said they felt staff were good at their jobs and had confidence that they had suitable training. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 16 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. The home is well run with the interests of residents taken into account. Systems for safeguarding residents monies has improved to ensure their protection. Procedures for health and safety the welfare promote the welfare of residents. EVIDENCE: The registered manager has been in her post for six years and is a registered nurse. She is currently undertaking her NVQ level 4, registered managers’ award and has already achieved an NVQ assessors’ award and is a trainer in environmental health. Residents and staff said they were able to talk to the manager about any concerns and had confidence in her to resolve their issues. As required previously a quality assurance questionnaire has been given out to residents. Minutes of their six weekly meetings were seen. There has been a Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 17 good turn out to these and minutes showed that ideas and concerns were raised and addressed. A requirement for a report and action plan from the results of the quality assurance to be drawn up has been made. Following a requirement for improved procedures for recording money looked after by the home, three residents’ monies were checked. Balances matched the amounts held and an accurate record of transactions had been made. Residents said they felt safe in the home and had confidence that staff followed the homes’ policies and procedures regarding their health and safety. For example, wearing gloves and aprons appropriately. Staff spoken to said they had received training in health and safety and were able to give examples of how they upheld the homes’ health and safety procedures. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 18 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X 3 X STAFFING Standard No Score 27 2 28 3 29 2 30 2 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.V279241.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP9 OP9 OP29 Regulation 13 (2) 13 (2) 19 Requirement The manager must produce and implement a safe procedure for the disposal of medicines. Medication must only be administered as prescribed. Recruitment procedures must be followed at all times, including two written references and a CRB being taken up The registered manager must provide suitable induction training to staff. (This is a repeated requirement from the inspections of 02/02/05 and 05/07/05) A report showing the results of a quality audit should be provided to residents. Timescale for action 01/03/06 01/03/06 01/03/06 3 OP30 18 01/03/06 4 OP33 24 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 20 1 OP14 A restriction made on a service user, highlighted during the inspection, should be risk assessed and documented. Beacon House DS0000011539.V279241.R01.S.doc Version 5.1 Page 21 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. 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