Inspection on 07/12/07 for Beacon House

This inspection was carried out on 7th December 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 13/06/07

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 Marilyn Lewis 7 th Unannounced Inspection December 2007 09:00 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.V349931.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.V349931.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.V349931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2007 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 registered manager stated on the 7th December 2007 that the home’s fees range from £520 to £650.00 per week. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the home took place on the 7th December 2007. The main aim of the visit was to follow up on the requirements issued during the last inspection, which took place on the 13th June 2007. During the visit the inspector met with residents, visiting relatives, carers, the deputy manager and the registered manager. Records were seen including care plans and risk assessments and those for medication, staff training and recruitment. Information received since the last inspection was also taken into account when completing this report. What the service does well: Residents said that they liked living at the home and they said that the staff were very good. Comments included ‘the carers are lovely’, ‘they always have time for you’ and ‘I have absolutely nothing to grumble about’. A visiting relative said that the home was ‘super’ and that his relative was being very well looked after. Residents said that they were able to participate in the wide variety of social activities as they wished and enjoyed the very good choice of meals provided. The home looked clean and welcoming and residents said that they liked their rooms, which they had personalised with items such as small pieces of furniture, pictures and ornaments. Good interaction was observed between staff and residents and there was a relaxed and friendly atmosphere. Staff said that they received good support from the registered manager and the deputy manager. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Beacon House DS0000011539.V349931.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 House DS0000011539.V349931.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): 1, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are provided with clear information about life at the home to assist them in making a decision about taking a place there. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. The home does not provide intermediate care. EVIDENCE: Since the last inspection the home’s Statement of Purpose has been reviewed to provide up to date information about life at the home for prospective residents and their relatives. A resident said that they had found the information very useful when making a decision about moving into a home. Three residents spoken with said that they Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 10 had visited the home to view the property and meet with other residents prior to taking a place there. The registered manager said that prospective residents and their relatives were encouraged to visit the home and other homes in the locality before making a decision about where to live. At the last inspection documents regarding pre admission assessments had not been fully completed and it was therefore not possible to confirm that the assessments had been undertaken. A pre admission assessment seen during this visit, for a resident who had been admitted since the last inspection, indicated that all aspects of care provision including mobility, continence, speech and medication had been assessed prior to admission. Relevant information from the care manager and health professionals was included in the assessment report. The registered manager said that some residents admitted for respite care later became residents and knew the home, staff and other residents before they moved in permanently. The home admits residents for respite care but does not provide intermediate care and therefore standard 6 is not applicable. Beacon House DS0000011539.V349931.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): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning has improved but further improvements are needed to ensure all the care needs including the health needs of the residents are recorded and to provide clear guidance for staff on the support required to meet the residents’ needs. Residents are protected by staff adhering to the home’s procedures for dealing with medicines. Residents are treated with respect at all times but at times their right to privacy is not upheld. EVIDENCE: At the last inspection care plans did not contain all the information needed to provide staff with clear information regarding the care needs of the residents or the actions required to meet those needs. Three care plans were seen on this visit that indicated some improvement had taken place but more details were still required. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 12 Good information was documented for one resident who could be affected by mood swings. The triggers for when the mood swings were likely to take place had been identified and guidance was provided for staff on how to assist the resident through the incidents. Another of the care plans gave guidance to staff on how to support a resident who became very anxious at times, such as giving one to one attention or taking the resident for a walk in the garden. A staff member spoken with was aware of this guidance. The care plans also noted the residents’ preferences for daily living activities such as when they would like to get up and go to bed and daily records seen indicated that this information was correct. The plans also documented the residents’ social or cultural needs and any dates when they might wish to follow a tradition such as at Easter time. However one care plan stated that the resident needed assistance from a carer to have a bath but did not identify what the assistance required was or what the resident was able to do for them self to maintain their independence. A moving and handling and risk of falls assessment had not been completed for a resident admitted to the home four weeks previously. The registered manager said that staff were taking time to observe the resident before completing the assessments. An initial assessment should have been completed and reviewed as changes to the resident’s abilities were noted. Resident or their relatives had signed the care plans seen. Two of the care plans seen had been reviewed at four monthly intervals and this needs to be increased to reflect the changing needs of the residents. Staff were very aware of the needs of the residents and the support they required but some of the information was not documented to ensure the residents received consistent care. Care plans for one of the residents contained a nutritional assessment that indicated the resident was at very high risk and should be offered supplement drinks between meals but there were no records to confirm this was taking place. There was also no indication of the food items the resident liked or disliked to guide staff as to what they could offer if the resident did not want to take the meals provided. A staff member said that the resident was encouraged to take nutritional supplement drinks between meals but confirmed this was not being recorded. The registered manager said that the method of risk assessing for nutrition was being changed to provide a clearer format for staff but while this is being put in place records must be kept up to date to ensure any resident at risk regarding their nutritional well being are provided with the food they require to sustain them. There was evidence in the care plans for another resident to indicate the registered manager had asked advice from the GP regarding the residents’ loss of weight and recent falls. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 13 Following the visit the registered manager notified the inspector that nutritional assessments had been updated for the residents and staff had been instructed to notify either the registered manager or deputy manager regarding any changes to the nutritional intake or the weight of residents, so that the appropriate actions could be taken. Records seen indicated that residents were visited by their GP when needed and advice was sought from specialist nurses as needed. Visits to hospital outpatient departments were also documented. Residents spoken with said that staff arranged for a GP visit or for them to go to the surgery as they requested. A visitor also said that staff were quick to obtain advice from the GP when their relative was ill. The deputy manager discussed the home’s medication procedures with the inspector. Systems are in place for recording medication brought into the home and on the disposal of unwanted items. Medication records seen had been completed appropriately and medicines were stored safely. When medication was being administered one resident who was prescribed medication for pain relief on an ‘as needed’ basis was asked if she would like the medication and it was not just administered without reason. Records seen indicated that when an ‘as needed’ medicine was administered the reason for giving it was documented. At the time of the visit no drugs were stored in the controlled drugs cupboard or in the medication fridge. The deputy manager said that staff received training in the administration of medication and records seen confirmed this. Information available on medication was out of date and the registered manager said that she would obtain a new copy to ensure staff had up to dated information on the medicines they were administering. The deputy manager said that one of the residents was prescribed a medicine that increased the risk of bruising and it is advisable that a risk assessment is completed in regard of this. All residents spoken with said that staff treated them with respect. During the visit staff were seen to knock on doors and wait before entering rooms and they spoke to the residents in a friendly but respectful manner. However during the visit the chiropodist was attending to residents in one of the lounges and although only residents waiting to have treatment were in the room the door was open and visitors to the home were able to see what was happening. The registered manager spoke with the chiropodist and arranged for treatment to take place in the residents’ rooms in the future to provide them so that their privacy could be respected. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to participate in a wide range of social activities, maintain contact with family and friends and exercise choice over their lives. Residents enjoy the variety and choice of meals provided. EVIDENCE: One resident, who did not wish to attend church services, but who wished to watch services on television had enjoyed watching the Remembrance Day Service and another resident said that they went to a local church with relatives when they wished. A communion service is held at the home each month by a local minister and residents are able to attend as they wish. Some residents had recently joined members of a local church for a treasure hunt and the deputy manager said that she was hoping to arrange more activities with community groups in the near future. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 15 The deputy manager said that she was responsible for the programme of activities. The programme included in house activities such as exercises to music, bingo, scrabble, art and craft and music from visiting entertainers. At the time of the visit one resident was using an area of a landing for painting and some of the pictures she had painted in the past were displayed on the walls of the stairway. A record of trips out was kept in a book in the reception area. Residents said that they very much enjoyed the trips out which have included visits to the theatre, cinema and museums and places of interest in the locality. The deputy manager said that some events were held to which relatives and friends were invited such as a Bonfire Night event held recently. Some of the residents are able to go out into the community to visit friends and attend social activities independently. One resident said that she was able ‘to do her own thing’ and another said that staff always told her what activities were due to take place but allowed her to decide for herself whether she wished to join in or not. Residents said that they had ‘plenty to do’ and the activities programme was discussed with them during resident meetings when new ideas and suggestions were put forward. The programme of activities is displayed in the home and the deputy manager said that a copy is given to relatives so that they can arrange for their visits not to clash with an activity they feel their relative would enjoy. The recording of activities in residents’ daily records related mainly to the organised events and not for one to one sessions. Speaking with staff and residents it was evident that one to one activities were taking place but were not recorded. The registered manager said that she would address this during staff supervision sessions so that a clear record of activities was documented for each resident including details of whether they had declined the offer to participate in a session. The home has an open visiting policy and visitors spoken to, said that they were always made to feel welcome at the home. One resident said that she sometimes had three or four friends visiting at the same time and staff were quick to bring additional chairs to her room for her guests. During the visit it was evident that residents were able to exercise choice and staff were observed asking residents what they would like to do, where they would like to sit and what they would like for their meals. The care plans for one resident documented the resident’s right to smoke if she wished and arrangements had been made for this to take place in a covered area outside near the office. Residents said that they enjoyed the meals provided and that there was a good choice of food for each meal. The registered manager said that comments received during a resident meeting regarding the first course for lunch had been acted upon and a wider variety of starters were now offered. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 16 The home employs a cook and a relief cook to provide the meals both for the residents of the home and for people with low support needs who live in the bungalows in the grounds of the home who join the residents for lunch. On the day of the visit a choice of asparagus soup, grapefruit or melon was offered for the first course with scampi or lasagne with chips and a medley of vegetables the main courses. These were followed by pineapple upside down cake, yoghurts or cheese and biscuits. The meals were well presented and the atmosphere in the dining room was relaxed. Residents were able to take their meals in their own rooms if they preferred. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their complaints will be taken seriously and they are protected by staff awareness of the need to protect vulnerable people. EVIDENCE: Since the last inspection the complaints procedures have been reviewed and now provide clear information regarding making a complaint. Residents and two visitors spoken with said that they would take any complaints to the registered manager or the deputy manager and they felt actions would be taken to resolve the issue quickly. The registered manager said that no complaints had been received since the last inspection. A staff member said that if a resident said that they wished to make a complaint she would bring it to the attention of the registered manager as it was the resident’s ‘right to make a complaint’. At the time of the last inspection a requirement was issued for all staff to receive training in the prevention of abuse. Staff said that they have now received the training and records seen confirmed this. Procedures were available for staff including Hampshire County Council’s Protection of Vulnerable Adults and Whistle Blowing. Two staff members Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 18 spoken with regarding adult protection were aware of the procedures to follow should abuse be suspected. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beacon House provides a clean, safe and homely environment for all who live and visit there. EVIDENCE: The home is a detached property situated in a quiet residential area of Fleet. Several bungalows for people with low support needs are in the grounds of the home and as previously stated people from the bungalows join residents of the home for meals if they wish. The home looked clean, welcoming and well maintained. Residents have access to the two lounges and separate dining room. Accommodation is provided over two floors with stairs and a passenger lift allowing access to each floor. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 20 Residents said that they liked their own rooms with one resident commenting ‘I really appreciated being able to bring some of my personal belongings into the home with me. They hold such memories’. Another resident said that her room ‘was lovely’ and there were also comments of ‘my room has all I need’. Rooms seen were spacious and contained many personal items such as small pieces of furniture, pictures and ornaments. Residents said that they were able to have their own telephone if they wished. Some of the rooms look out onto a wooded area and residents said that they really enjoyed sitting watching the birds and squirrels. All of the residents are accommodated in single rooms and each has their own bathroom with toilet situated close to their room. The bathrooms seen looked clean and well maintained. The registered manager said there is an ongoing programme of redecoration and refurbishment for the home and at the time of the visit a landing and stairway were being redecorated. Three new chairs have been ordered for one of the lounges and new curtains have recently been fitted in the lounges. The registered manager said that new carpets are to be fitted shortly. The top floor of the home is used for staff accommodation and is not accessible to residents. The home has large gardens with seating areas provided. Residents said that they enjoyed spending time in the gardens during the warm weather. Staff said that protective clothing such as disposable aprons and gloves were readily available and they were seen to use them as needed. The laundry room has hand- washing facilities and looked to be in good order at the time of the visit. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff levels are flexible to ensure the needs of the residents can be met and staff receive the training they require to do their jobs. Residents’ safety is protected by the robust procedures used for the recruitment of staff. EVIDENCE: All residents spoken with said that the staff were very good. Comments included ‘they can’t do enough for you’, ‘always friendly and kind’ and ‘they really are lovely’. At the time of the visit four carers were on duty together with the deputy manager, the cook, a domestic and the handyman. Staff said there were enough people on duty as some of the residents were fairly independent and did not require support for personal care or one to one activities. The home currently has two vacancies and one resident is in hospital so there were seventeen residents accommodated. Three residents asked, said that they did not have to wait long for staff when they requested assistance. The registered manager said that the staffing levels were flexible dependent on the dependency levels of the residents and the social activities taking place. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 22 Rotas seen indicated that staffing levels had been increased when one resident had been very poorly and her dependency levels were high. The home employs the registered manager, deputy manager, assistant deputy manager, a senior carer and seventeen carers plus separate staff for catering, and domestic duties. The registered manager said that she now has allocated management time as a part time administration assistant has recently been recruited to assist with administration work. Staff said that they were encouraged to obtain training qualifications and ten staff members now hold National Vocational Qualification (NVQ) level 2 or above in care and two more are due to start in the New Year. Three staff members have expressed an interest in going on to do NVQ level 3 and the registered manager said that this is being arranged. Records seen indicated that staff had received training in the protection of vulnerable adults and infection control, fourteen had attended sessions for food hygiene and twelve for first aid. Staff received refresher training in moving and handling on an annual basis and the registered manager said that a staff member was doing a training course to enable her to train the staff in moving and handling as in house training. The registered manager said that she had purchased new training packs that would improve the training programme for staff. Health and Safety, Nutrition and Risk Assessment training sessions have been arranged for staff for 2008. Some staff had received training in dementia care two years ago and the registered manager said she was arranging for more staff to attend in 2008. Records seen at the last inspection demonstrated that the home was following appropriate recruitment procedures to safeguard the residents. No new staff have been recruited since the last inspection so recruitment records were not inspected but appropriate systems are in place should new staff be employed. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager runs the home in the best interests of the residents. However the registered manager needs to concentrate on the improvements that have been made in order to ensure they are sustained and to ensure further improvements are made with regard to record keeping. EVIDENCE: The registered manager, Ms Janet Deaville, is a trained nurse and an NVQ trainer, assessor and verifier. Ms Deaville said that she is currently undertaking the Registered Managers Award, which she hopes to complete in the spring of 2008. The registered manager has implemented changes and is developing new systems to improve the quality of care provided at the home. However as Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 24 previously stated in standards 7 and 8 further improvement is needed in the recording of information in care plans and health care records. Improved recording is also needed for one to one activities with residents. Residents and staff spoke very highly of the registered manager. All said that she was easy to talk with and that she offered very good support. Visitors said that there was very good communication with the registered manager. It was evident during the visit that the registered manager has a very good rapport with the residents, staff and visitors. Since the last inspection the registered manager has delegated some responsibilities to the deputy manager and assistant deputy manager and has the support of the administration assistant. The registered manager said that this has given her time to concentrate on areas of concern highlighted at the last inspection and to improve the quality of the care provided. Many of the requirements of the last inspection have been met at this inspection but further improvements are needed particularly in the recording of health care needs and one to one activities. The registered manager said that a system to monitor the quality of the care provided has been implemented. Staff meetings have been held for care staff and ancillary staff and the registered manager has also met with night staff. A staff member said that the meetings were helpful and provided a good opportunity to discuss any changes to the procedures. Meetings are also held for the residents. At the last inspection residents said that they felt people living in the bungalows who joined their meetings had different issues that they wished to discuss and since then the registered manager has held separate meetings for residents and the people living in the bungalows. A resident said that she felt the separate meetings made it easier to discuss issues relating to the care provided in the home. Records of the meetings indicated that they were taking place at two monthly intervals and feedback on issues raised at one meeting was provided in the next meeting. The registered manager has prepared questionnaires for residents, staff, visitors, GPs and district nurses to obtain their views on the quality of care being provided at the home. The questionnaires are due to be given out after the Christmas and New Year period. One of the directors of the company visits the home unannounced each month to monitor the quality of care provided. The home holds small amounts of personal money for some residents. The money is stored safely and records seen for three residents matched the money held. Receipts are kept for all transactions. All bar two of the staff members have received supervision since the last inspection where a requirement was issued, as formal supervision was not taking place. The registered manager said that supervision included observing Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 25 staff interaction with residents and one to one meetings to discuss performance and personal development. The deputy manager has taken the responsibility for supervision of ancillary staff as she also takes the lead in catering and housekeeping issues. The registered manager has obtained an appraisal and supervision pack and there was evidence to confirm the supervision sessions were taking place. Staff said that they had received training in fire safety and attended fire drills and records confirmed this. Fire records seen indicated that checks on fire safety equipment took place as needed. Maintenance records also indicated that regular checks were made on electrical equipment and the lift. Two new general boilers had been fitted recently. Health and safety notices were displayed around the home and substances hazardous to health such as cleaning fluids were stored safely. Records seen indicated that all accidents that take place in the home are recorded and the registered manager is auditing the records to identify any issues that need addressing. Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 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 2 x 2 Beacon House DS0000011539.V349931.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement Care plans must provide details of all the resident’s care needs and the actions required by staff to meet those needs including health care needs. (This is an amended requirement of the inspection dated 13/06/07) Residents right to privacy must be upheld when receiving personal care, including care given by the chiropodist. Timescale for action 31/01/08 2. OP10 12 (4)(a) 31/12/07 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.V349931.R01.S.doc Version 5.2 Page 28 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.V349931.R01.S.doc Version 5.2 Page 29 - 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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