Inspection on 13/02/06 for Beacon House Nursing Home

This inspection was carried out on 13th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Nursing Home 03/12/08

Beacon House Nursing Home 03/10/06

Beacon House Nursing Home 11/08/05

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 Sarah Middleton Unannounced Inspection 13th February 2006 09:40 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 Nursing Home DS0000010965.V280452.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 Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 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) 020 8813 8713 020 8574 2549 vimala@beaconcare.com Mr Gurpal Singh Gill Mrs Akhtar Unnisa Sher Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 home can accommodate service users over the age of 20 years Date of last inspection 11th August 2005 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 an 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. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 almost six and half hours, 9.40am-4.05pm, was spent on the inspection process. The Inspector carried out a tour of the home and inspected service users plans, staff files and maintenance records. Four service users, four members of staff and one visitor were spoken with as part of the inspection process. Currently the home does not have a Registered Manager. This person left the home in 2005. The Finance Director, who has worked in the home for several years, currently manages the day to day running of the home with the assistance of the Registered Provider and qualified nurses. The Finance Director assisted the Inspector with this inspection and will be referred to in this report as the Manager Designate. The Registered Provider was not present at this inspection. The Manager Designate and the Registered Provider are aware of the importance to have a Registered Manager for the home as soon as possible and are making the necessary plans to address this situation. Overall feedback from staff, service users and the visitor was that the changes in staff a few months earlier had not had an impact on the care and standards of the home. There were three service user vacancies and no staff vacancies at the time of the inspection. The previous six requirements had been met and five new requirements were made following this inspection. This report should be read in conjunction with the previous inspection on 11th August 2005 to obtain a full picture of the home and to view the Standards inspected. What the service does well: The home provides a safe and welcoming home for the service users. Staff are committed to working together in the interests of the service users and are aware of individual service users needs. Service users feedback indicated that staff are caring, professional and approachable. Care plans and risk assessments are detailed, up to date and offer clear information for staff to know how to appropriately care and support the individual service user. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Although some activities are in place, the home needs to continuously consider if there are sufficient opportunities for service users to maintain interests they might have and to keep service users occupied and stimulated. For some service users they might wish to go out into the community and the home must consider ways to support service users accessing leisure and community facilities. Meals must be recorded, in order for the home to monitor the food individual service users are eating and to ensure they are eating enough food that is nutritious and healthy. Staff employment files must contain all the necessary required documentation listed in Schedule 2, for example, references and medical declaration. In addition Management must be satisfied that the employment history and references offer Management sufficient details regarding the applicant. These documents and the information provided by an applicant are important in order to safeguard and protect service users. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 7 Fire drills had taken place regularly however it was not always clear what staff members had been involved with the fire drill. Names of staff attending fire drills must be recorded to ensure all staff take part in fire drills throughout the year. Thus ensuring that all staff can respond effectively in the event of a fire. Finally all servicing records must be up to date, for example the Gas Safety record was just out of date. The home must ensure all equipment is serviced within the safe timescale in order to protect the health and safety of all who live, work or visit the home. 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 DS0000010965.V280452.R01.S.doc Version 5.1 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 Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Service users are assessed prior to admission to ensure the home can meet their needs. The home obtains as much information regarding the service user from both the service user and relevant persons in order to have a full picture of the service user. Prospective service users and their representatives are encouraged to visit the home in order to make an informed choice. EVIDENCE: Pre-admission assessment documentation was viewed on a recent admission. These are usually completed by the qualified nurses who visit the service user to gather as much information as they can. These assessments were detailed and indicated the prospective service users needs, including their mobility, communication, health and personal care needs. In addition, the home seeks to obtain assessments, reports and risk assessments from the referrer and others and then considers these documents in conjunction with the home’s own assessment. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 10 The Manager Designate confirmed that where possible service users and/or their representatives are encouraged to visit the home and meet other service users and staff. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 The health and personal care needs of service users had been identified and were being met. Documentation was detailed and gave a clear insight into the individual’s needs. The medication systems in place were robust and safeguarded service users health and safety. EVIDENCE: Individual service user plans were available and viewed. These were very comprehensive, individual and detailed how the service users identified health; personal and social needs would be met. Service users plans were up to date and had been reviewed monthly or whenever there had been a change in the service users needs. Service users had signed their care plans indicating that staff had made attempts to involve the service user in the completion and/ or the review of their needs. Daily records were available and detailed the care provided. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 12 Assessments for moving and handling and nutritional screening were in place. Risk assessments had been completed and reflected the individual risks service users faced, such as having bedrails, using a wheel chair and risk of falling. These had been reviewed and updated where necessary. The home did not have any service users with pressure sores at the time of the inspection. Where service users were at risk of developing pressure sores, this had been noted on care plans and appropriate documentation, such as the Waterlow assessment had been completed. The Manager Designate confirmed that pressure-relieving mattresses are used for those needing this care prevention support. The home has various health professionals regularly visiting the home such as Chiropodists, GP, Physiotherapist and a Dentist. These visits are documented along with any treatment plan. Staff support and escort service users when they have external health appointments. Samples of medication administration records were tracked. These had been completed correctly. Controlled drugs are used in the home and these had been stored and recorded appropriately. Nurses and adaptation nurses administer medicines. Adaptation nurses are supervised by qualified nurses, when they administer medication. A sample of service users medicines were counted and were correct as noted on the medication record sheets. The home has a contract with a company for the safe disposal of medication. The fridge temperatures, where medicines are stored had been taken on a daily basis and were recorded within an appropriate range. Liquid medicines, including eye drops, had dates of opening written on them. Labels were no longer being used on medication records. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Some activities are in place however the home must consider ways to develop a more structured regular programme of activities to include using community facilities. Visiting is encouraged for service users to maintain contact with family and friends. Service users choices in their care and abilities are respected within the home’s capabilities. Meal provision is varied and aims to provide choice and a well balanced diet in order to promote good health. Staff must record the meals service users eat to ensure service users are receiving sufficient and varied meals on a daily basis and to monitor any changes in eating patterns. EVIDENCE: The home does not have an activities co-ordinator; therefore staff engage service users in various activities. Staff spoken with indicated that where possible they provide stimulation and occupation for the service users. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 14 However the Inspector made a requirement that the home must consider providing more structured activities on a daily basis and that service users should also have the opportunity to go out into the community. Service users spoken with said there was not always something for them to take part in on a regular basis and one service user stated they would like to have the option of going out and visiting a pub. This was feedback to Management. Service users previous employment is usually noted on care plans and their likes and dislikes. This information should form part of planning meaningful activities that meet individual preferences and interests. This requirement was discussed with the Manager Designate and nurses in order for the home to recognise the importance of occupying service users as part of every day life. A visitor spoken with commented positively on the home and stated they were involved with the care their son received. They confirmed the home had kept them informed of any changes regarding their son’s welfare. They were able to visit whenever they can get to the home and they said they were made to feel welcome by all the members of staff. Service users confirmed they see their visitors either in the lounge area or in private. Service users maintain autonomy through taking care of their own finances, or with the assistance of their relatives. Where possible, service users make decisions every day, for example, where they eat their meals and when they get up/go to bed. The lunch was sampled and was well presented and tasty. Overall service users commented positively on the meals provided in the home, one service user said they had made several requests for alternative brands to be used but that the home had not listened to their request. This was discussed with the Manager Designate, who was aware of this service user’s requests and that they had regularly discussed this issue with the service user. This service user often orders takeaways and keeps the food in their room. This was discussed with the Manager Designate and nurses as the home must monitor how the food is stored and when it is eaten to ensure the service user’s health and welfare is not jeopardised. The kitchen was viewed and was clean and tidy. The cook provides meals to meet the needs of the service users, for example, one service user is vegan, whilst some others need soft food. Menus are based on a four-week rolling programme and incorporate a variety of fresh produce. Staff were seen to assist some service users in feeding them and this was carried out in a sensitive and unhurried manner. The home had not recorded the meals service users ate, including any alternative meals. This must be carried out and was made a requirement. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a complaints procedure in place and service users were confident their complaints would be listened to and acted upon. Systems were in place for the protection of vulnerable adults. EVIDENCE: The home has a clear complaints procedure, which is freely available. One complaint had been recorded in the past two years and the action taken by the home to investigate the complaint along with copies of all correspondence was available and had been appropriately dealt with. This complaint was now closed. The CSCI had not directly received any complaints. Those service users and the visitor asked, stated they would feel able to take any concerns or issues to Management and that they felt they would be listened to and where possible the home would address any complaints. The home has a clear procedure for the protection of vulnerable adults, (POVA). Staff had received training in POVA and this was a regular subject covered internally by the home. There had been no POVA investigations regarding the home. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 & 26 The environmental standard of the home was good and the home was free from any malodours. The home is well maintained and items are replaced or updated as and when necessary. The communal areas are sufficient in size to offer service users a comfortable home to live in. Service users bedrooms were appropriate to meet their individual needs and preferences. The home was clean and procedures and systems were in place to minimise the risk of infection. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 17 EVIDENCE: A tour of the home was carried and a sample of rooms viewed. These were being satisfactorily maintained. There is a housekeeper who maintains the general cleanliness of the home. The home was bright and tidy with appropriate furniture and furnishings at the time of the inspection. The Manager Designate confirmed the home replaces items in the home and redecorates as and when needed. There is a communal lounge on the ground floor that is sufficient in size. The conservatory is for service users who smoke. In addition there is a small garden that service users access in the warmer weather. Personal preferences are respected and service users can spend time in the communal areas or in their bedrooms. Samples of service users bedrooms were viewed and were spacious and personalised. Service users wanting to watch “Zee TV”, which is specifically for Asian viewing can do so in their bedrooms. Those bedrooms that were double/shared rooms had screening to ensure service users have privacy. Service users can lock their bedrooms if they wish and lockable storage is available. The home was free from offensive odours at the time of the inspection. The laundry room was seen and the laundry person working there had received training in infection control. Service users spoken with were happy with the laundry service in the home. Protective clothing was seen in bathrooms and toilets. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 The staff team are able to study and obtain qualifications such as an NVQ to ensure they have the skills and knowledge to meet the needs of the service users. The shortfalls in recruitment procedures could pose a risk to service users and must be addressed immediately. Staff are trained in various subjects to ensure they are competent to do their jobs and care for service users appropriately. EVIDENCE: The home has a few members of staff who have either obtained an NVQ or are in the process of studying for this qualification. The Manager Designate is aware of the need to ensure a minimum of 50 of staff, excluding qualified nurses, have a relevant and up to date qualification, such as NVQ. Three nurses left the staff team last year, however several adaptation nurses, who then qualified, joined the staff team as nurses. Those asked stated the departure of the other nurses did not have an impact on the service or the existing members of staff. There were no staff vacancies at the time of the inspection. There were major shortfalls regarding some of the staff files viewed. On one file there was no application form and on two files there were no references or medical declarations to state they were fit to work at the home. One staff file did not contain a photograph of the member of staff. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 19 All staff files viewed contained Criminal Record Bureau checks. The shortfalls were discussed with the Manager Designate who said that some of the documentation were stored elsewhere. The Inspector emphasised the need to ensure all documents listed in Schedule 2 were available for inspection and a requirement was made regarding staff employment records. In addition discussions took place with regards to ensuring a full employment history is obtained prior to the applicant being employed in the home. The Manager Designate acknowledged the need to gather a full history of an applicant and will consider reviewing the application form to ensure this is obtained. There was written evidence of staff induction training and the Manager Designate confirmed new staff were supervised and shadowed existing staff to ensure they were slowly introduced to the routines and practices in the home. The induction programme ensured staff were familiar with a range of skills and information necessary for them to know, such as policies and procedures and service users routines. A qualified nurse who visits the home every fortnight and is an assessor and trainer also provides ongoing training. They offer training and information on various subjects relevant to the staff team. In addition staff attend mandatory training courses, such as moving and handling, fire safety and health and safety. A training matrix had been devised for the Manager Designate to monitor staff development and to ensure staff attend regular updates and refresher training as and when required. Staff spoken with stated they were happy with the level of training they received and that the training provided met their needs and consequently met the needs of the service users. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Although there is not a Registered Manager in post, the home is well managed and staff can seek support and guidance from the Manager Designate and/or the Registered Provider. Systems are in place to monitor the quality of care offered in the home. Service users and their representative’s views are obtained in order for the Management to run the home in the interests of the service users. Currently the home does not manage service users finances. Fire drills must record the members of staff who attend in order to ensure staff can respond effectively in the event of a fire. Overall servicing records were up to date, however the Gas safety Record was not. This must be up to date to protect the health and safety of the service users. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 21 EVIDENCE: Currently the home does not have a Registered Manager and so this Standard can only partially be inspected. Currently the Manager Designate is in charge of the day to running of the home and has worked as the Finance Director for several years. However they do not work full time and discussions took place with the Manager Designate regarding ensuring there is management support for staff on a daily basis. Clinical supervision is provided by an external nurse. They meet with staff and offers one to one supervision for nurses regarding any clinical issues. This nurse does not work in the home and visits every fortnight, or whenever it is deemed necessary. The Manager Designate and the Registered Provider have enrolled to study for the Registered Managers Award. This is due to commence in the next few weeks. The Registered Provider is aware of the need to have a Registered Manager working in the home to provide consistent direction and support to staff and service users. Those staff and service users asked stated that although the Registered Manager had left the home there had been no problems within the home and that there was always a senior member of staff or the Registered Provider to call on if support or advice was needed. Staff and service users stated the Manager Designate and Registered Provider were always available and approachable if they needed to talk with them. The Manager Designate had reviewed the policies and procedures in the home and had made several changes to the organisation of the home. All staff were now aware of the general day to day running of the home to ensure the staff team were equipped with knowledge and information relevant not just to their role but regarding some of the operational aspects of the home. Staff spoken with felt more involved and confident to handle a variety of scenarios and queries put to them. Approximately every six months questionnaires were given to service users and relatives to complete on the home, this includes asking them if they are happy with the choices and privacy they receive in the home. Once a year an external company visits the home to carry out their own audit. Their recommendations are feedback to the Management team. The home does not handle service users finances, as usually the service user or their relative/representative manages their finances. The Inspector discussed with the Manager Designate the need to include information in the Statement of Purpose and Service Users Guide regarding the homes stance on not handling service users finances. On the rare occasion a service user might ask Management to take out some money from their account, or handle their finances, the Inspector advised the Manager Designate that appropriate procedures must be devised and systems put in place before Management handle any service users money to ensure both the home and service users welfare is protected. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 22 Servicing records were viewed at random. The testing for Legionella was up to date. Water temperatures had been taken on a regular basis. Fire drills had been occurring, although the names of members of staff who had been present were not always recorded. This is a requirement. Finally the Gas Safety Record was just out of date, a requirement was made that this must be up to date. The Manager Designate stated that this was due to be serviced the following week. Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x 3 x 3 STAFFING Standard No Score 27 x 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x x 2 Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP12 Regulation 16(m)(n) Requirement The Registered Person must ensure there are sufficient opportunities for services users to take part in activities both in the home and in the community. All meals must be recorded, in particular where service users eat an alternative meal from the set menu. Each staff employment file must contain an application form, signed medical declaration, photograph & 2 references. These must be available for inspection. The Gas Safety Record must be up to date and available for inspection. All staff must attend fire drills/practices held throughout the year. Their names must be recorded to ensure all staff can respond appropriately in the event of a fire. Timescale for action 31/05/06 2. OP15 Schedule 4 Schedule 2 14/02/06 3. OP29 28/02/06 4. 5. OP38 OP38 13(4)(a) 23(4)(c) (iii)&(e) 28/02/06 28/02/06 Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 25 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 Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection West London Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Beacon House Nursing Home DS0000010965.V280452.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!