Inspection on 11/08/05 for Beacon House Nursing Home

This inspection was carried out on 11th August 2005.

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 Nursing Home 03/12/08

Beacon House Nursing Home 03/10/06

Beacon House Nursing Home 13/02/06

Beacon House Nursing Home 03/02/05

Beacon House Nursing Home 05/07/04

Beacon House Nursing Home 26/01/04

Beacon House Nursing Home 23/09/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Beacon House Nursing Home 184 Beaconsfield Road Southall Middlesex UB1 1EA Lead Inspector Rekha Bhardwa Unannounced 11 August 2005 at 11:50 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 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 Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beacon House Nursing Home Address 184 Beaconsfield Road, Southall, Middlesex, UB1 1EA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 813 8713 0208 574 2549 vimala@beaconcare.com Mr Gurpal Singh Gill Mrs Akhtar Unisa Sher CRH 19 Category(ies) of Physical Disability over the age of 20 years, registration, with number Physical Disabilty - Over 65 and Old Age of places Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service User to include PD,PD(E)& OP, not exceeding 19 persons. None of the three additional bedrooms should be occupied by a wheelchair user. The heating controls on the radiators in the three new bedrooms must be adjusted so that the service user can independently control the temperature. This must be done within three months of the Variation being granted. The home can accommodate service users over the age of 20 years. Date of last inspection 3/2/05 Brief Description of the Service: Beacon House is a Nursing Home for 19 service users situated in Southall West London.The Home is a purpose built Tudor style building on three floors.There are eleven single bedrooms and 4 double bedrooms. There is one lounge, a conservatory and a dining room on the ground-floor. A lift is available. There is a enclosed garden at the rear of the home which can be accessed via the conservatory. The home is located within walking distance of Southall. Public transport is available nearby in the form of buses and the railway station.On the day of the inspection there were no vacancies. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 5 hours were spent on the inspection process. The Inspector undertook a partial tour of the premises and inspected, service user plans, training records and servicing records. Service users, visitors and 5 staff were spoken to as part of the inspection process. At the time of the inspection there were 16 service users accommodated at the home. The Registered Manager was not available at the time of the inspection therefore the standards in relation to the Registered Manager have not been assessed at this inspection What the service does well: What has improved since the last inspection? What they could do better: Pre-admission assessments must be completed in full in order that staff obtain a full picture of the needs of the service user. All assessments in relation to the service users moving and handling must be in place. Service user plans must be up dated where required following review. Discussions with the dispensing pharmacist must take place to ensure that stickey labels are not used on Medication Administration Records. Arrangements must be in place for the disposal of medication through controlled waste. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 6 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 Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 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 standard(s) 1,3,4, and 5 Service users are provided with written information about the home. Service users are assessed prior to admission to ensure that the home can meet their needs. Pre-admission assessments must be completed in full, to ensure that the needs of service users are fully assessed and met. Staff have received training to meet service users needs, including specialist needs. Prospective service users and/or their representatives are encouraged to visit the home in order to make an informed choice. EVIDENCE: Service users, their relatives and representatives are provided with information regarding the home in the form of a Service Users Guide and Statement of Purpose. The Statement of Purpose has been reviewed since the last inspection. Needs Led Assessments completed by the Social Worker were available on two files viewed. The home also undertakes their own pre-admission assessment in order to assess whether the needs of the service user can be met by the home. Two of these assessments were viewed, one was completed in full the other Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 9 was incomplete. It was not clear whether all the service users had been assessed for NHS funded nursing care, the Senior Nurse agreed to this with Ealing PCT. Staff had received training in topics relevant to the service user group at the home. The Registered Provider said that whenever possible, prospective service users are encouraged to visit the home, and meet other service users and staff. However it is usual for a representative of a service user to visit on their behalf. The home does no accept emergency admissions at the present time. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Service users individual needs were not always reflected in the plan of care, reviews were taking place but information held was not always up to date, and this can place service user at risk of not having their needs fully met. Shortfalls in completing moving and handling assessments place service users at risk. Generally medications were being well managed, so as to ensure that service users medication needs are met. Shortfalls identified in relation to labels and disposal must be addressed to ensure service users safety. Service users were being treated with courtesy and respect. EVIDENCE: A new system of care planning had been introduced and had been in place for one month. Individual service user plans were available and samples were viewed. These were generally comprehensive and detailed how the service users’ identified health, personal and social care needs were to be met. One plan for a heel wound was continuing to be reviewed even though the wound had healed. For one service user weight gain had been identified as a need, however this was not reflected in the plan of care. The service user plans had been reviewed Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 11 monthly, but updates had not always been included and the need to ensure that staff read through the service user plans thoroughly when reviewing them to ensure they are accurate and up to date was discussed. There was evidence that the service user or their representative had been involved in the formulation of the service users plan. Daily records were being completed on each shift and detailed the care provided. At the time of the inspection there were no wounds or pressure ulcers. Pressure relieving equipment to meet the assessed needs of the service users was seen in use in the home. One file viewed did not contain a moving and handling assessment, the Senior Nurse was asked to address this at the inspection. Waterlow and nutritional assessments were available. Continence assessments are undertaken where this is an assessed need. Records viewed indicated that service users have input from GP, optician, physiotherapist, dietician, chiropodist and plus other health care professionals. Samples of the medication administration records were viewed. Overall these were well recorded. The Inspector noted that the MAR sheets were not printed with the prescription instructions but that the dispensing pharmacist had attached labels with prescription instructions. This is not a permanent record as the label can be removed. It was agreed at the time of the inspection that this would be addressed with the supplying pharmacist. The drugs fridge temperatures were within the required range. None of the service users were able to self medicate. The Controlled Drugs register was viewed and well maintained. The home was not aware of new legislation regarding the safe disposal of medicines in care homes with nursing. The Registered Provider agreed that he would contact the waste disposal company already used by the home to make arrangements for a system of safe disposal of medication. The Registered Provider also agreed that the policy and procedure in relation to medication would be updated to reflect this. Service users and visitors spoken with were satisfied with the standard of care provided and the attitude of the staff. Staff were seen to address service users in a courteous manner. Some service users choose to spend their time in their bedrooms rather than in the lounge area. Any examinations undertaken by the GP are carried out in the service users bedrooms. All toilets and bathrooms are lockable. Where service users like their bedroom door to be kept open, these have a Dorgard mechanism in place. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 Visiting is encouraged and this enhances the service users lives and maintains contact with their families and friends. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Visiting hours to the home are open. Visitors were seen visiting throughout the day. Service users can choose to see whom they wish to see and their wishes are respected. Visitors spoken with said that they are made to feel welcome and tea, coffee and soft drinks are offered. The lunch was sampled at the inspection this was well presented and tasty. A choice of meals is offered this includes vegetarian, vegan, non -vegetarian and halal diets. Small snacks, hot and cold drinks were observed being provided throughout the day. The kitchen was not inspected at this inspection. Service users who spoke with the Inspector were complimentary about the meal provision. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 and 18 The home has a clear complaints procedure and service users and relatives were confident that their complaints would be listened to, taken seriously and acted upon. Systems were in place for the protection of vulnerable adults. EVIDENCE: A complaints policy and procedure were in place. The Inspector was informed that no complaints had been received by the home since the last inspection. Service users who spoke with the Inspector confirmed that they knew the procedure for making complaints and that any concerns raised are addressed promptly. The Protection of Vulnerable Adults procedure was available and dovetailed with the Local Authority POVA documentation. Staff had received training in POVA. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,20,22 and 26 The home was clean and tidy and the environment is safe for service users. This provides service users with a comfortable and safe environment for those living in the home and visiting. The premises were well maintained, odour free and a pleasant living environment. Policies and procedures and staff training for infection control were in place to safeguard service users from infection. EVIDENCE: Beacon House is a purpose built nursing home. The home was well presented, clean and odour free throughout. Several of the bedrooms contained new bedroom furniture. There is a garden to the rear of the building, which is accessible via the dining room. There is a large lounge/dining area on the ground floor. This was well maintained, and had a homely atmosphere. Suitable adaptations to meet the needs of the service users were available throughout the home. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 15 The home was clean and odour free throughout. Gloves, aprons, soap and paper towels were available in the toilet and bathroom areas. Ongoing training on infection control was in place. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The home was adequately staffed to meet the assessed needs of the service users. Shortfalls in the training programme does not equip staff fully to meet the needs of the service users. EVIDENCE: Staffing levels on the day of the inspection met the needs of the service users. Staffing levels are kept under review by the Registered Provider to ensure that the changing needs of service users are met. Ancilliary staff are employed in appropriate numbers. Staff absence is covered within the homes bank staff team or overtime. Agency staff are not used. A training and development plan was shown to the Inspector. The training programme viewed covered 6 months of the year. It was not clear what provision was in place for NVQ training from this plan. The information provided was insufficient to determine the training needs of the staff team. The Inspector was informed by the Registered Provider that a tutor from Thames Valley University had been employed to undertake NVQ training every Saturday at the home. Beacon House is accredited by the Nursing and Midwifery Council as a teaching centre for the training of adaptation nurses. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 and 38 Meeting the needs of service users is a high priority for the staff team and the Registered Provider. The staff are approachable, professional and are skilled in caring for the service users. Systems for the management of health and safety are in place thus safeguarding service users. EVIDENCE: Service users satisfaction questionnaires are undertaken periodically. The home is registered to ISO 900012 standards. An annual audit takes place and the Registered Provider stated that the annual development plan or self monitoring methods are incorporated into the quality assurance system. Regulation 26 Visits are undertaken and copies of the report have been sent to the CSCI. The Registered Provider also visits the home on a daily basis and is available for service users to talk to, or raise any concerns. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 18 The Registered Provider informed the Inspector that Beacon House as a business has been developed to its full potential. As a result the plan for the business is to maintain full occupancy, have an ongoing programme of renewal and replacement. Servicing records were viewed at random and those viewed were up to date. The fire drill and fire alarm test records were up to date. There are comprehensive Health and Safety Policies and Procedures in place. Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 3 x x x 3 Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 20 yes 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. Standard 3 7 Regulation 14 Requirement Timescale for action 16/9/05 16/9/05 3. 4. 5. 8 9 9 6. 30 Pre- admission asssessments undertaken by the home must be fully completed. 15 Service user plans must be updated following a review/or change to ensure that up to date and accurate information is availablet. 13(5) Moving and handling assessments must be undertaken. 13(2) Labels on Medication Administration records must not be used. 13(2) A system for the safe disposal of medication must be in place. The medication policy and procedure must be updated to reflect this. 18(1)(a)(c A more detailed training )(i) programme must be devised and implemented with timescales and names of staff attending the training. The training programme must be written in accordance with the National Training Organisation (NTO) workforce training targets.(timescale of 31/3/05 not met) 16/9/05 16/9/05 16/9/05 26/9/05 Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Beacon House Nursing Home G61-G10 S10965 Beacon House V214849 11.08.05 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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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