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Inspection on 03/10/06 for Beacon House Nursing Home

Also see our care home review for Beacon House Nursing Home for more information

This inspection was carried out on 3rd October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a caring and homely environment for the service users to live in. Members of staff are experienced, committed and sensitive to the needs of the service users. In addition staff receive training on an ongoing and regular basis covering the various aspects of working in a nursing home. The home recognises the individual needs of the service users and works towards meeting all of the identified needs. Specialist professionals work in the home to assist service users, such as a full time Physiotherapist and activities co-ordinator.

What has improved since the last inspection?

The home, since the last inspection, has employed an activities co-ordinator. They now provide stimulation and occupation to those service users wanting to engage in the various activities that are now on offer. Meals are recorded, in particular when a service user has an alternative meal from the set menu. The Gas Safety record was up to date and fire drills had been held on a regular basis and the names of members of staff who attend the fire drills had been recorded.

What the care home could do better:

Staff employment files must contain all that is listed in Schedule 2 of the Care Standards Act 2000, this includes a recent photograph and a signed medical declaration from the applicant. The reviews that take place regarding the home and the views of service users and their family members must be developed into a summary or brief report that is then made available for service users and the CSCI. This summary must give an overall picture of the improvements that have taken place and the work that is still to be carried out. Thus ensuring that service users and family members are made aware of the improvements that have been carried out over the months and of areas the home has identified as needing further attention.

CARE HOMES FOR OLDER PEOPLE Beacon House Nursing Home 184 Beaconsfield Road Southall Middlesex UB1 1EA Lead Inspector Sarah Middleton Unannounced Inspection 3rd October 2006 09:30 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.V311251.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 Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 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.V311251.R01.S.doc Version 5.2 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 13th February 2006 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. The home currently has a Manager Designate, Deputy Manager, Nurses, carers, two housekeepers and a cook. The home also employs a Physiotherapist on a full-time basis and an activities co-ordinator, who works part-time. The fees range from £550 - £ 700 per service user, the fees depend on whether the service user is a younger or older person. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 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. The inspection was from 9.30am-4.35pm. The Inspector carried out a tour of the home and viewed service user files, an employment file and maintenance records. Equality and diversity issues and how the home meets this area has been looked at during this inspection. Five members of staff and four service users were spoken with as part of the regulatory process and their contributions, where appropriate have been used in this report. No visitors were spoken with at this inspection. The Manager Designate is in the process of applying to become the Registered Manager and they assisted with the inspection and will be referred to in this report as the Manager Designate. The Registered Provider was also present for some of the inspection. There are three service user vacancies in the home and no staff vacancies. Four of the five previous requirements were met. One requirement was restated and one new requirement was made at this inspection. All of the Key Standards were assessed during this inspection. What the service does well: The home provides a caring and homely environment for the service users to live in. Members of staff are experienced, committed and sensitive to the needs of the service users. In addition staff receive training on an ongoing and regular basis covering the various aspects of working in a nursing home. The home recognises the individual needs of the service users and works towards meeting all of the identified needs. Specialist professionals work in the home to assist service users, such as a full time Physiotherapist and activities co-ordinator. Beacon House Nursing Home DS0000010965.V311251.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. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3- ( The home does not offer Intermediate care) – Standard 6 N/A. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed to ensure the home can meet those identified needs successfully. EVIDENCE: The Inspector spoke with the two Lead Nurses, who carry out assessments on prospective service users. The usual process is for the referrer to forward on to the home information relating to the prospective service user, such as assessments, risk assessments and any other relevant reports. The nurses then visit the prospective service user at least once to gather an insight into their needs. As pre-admission assessment was viewed and this covered a wide range of subjects such as the service users medical diagnosis, medication, their family contact, mobility, nutrition and personal care needs. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 9 Family and /or the prospective service user are then encouraged to visit the home and spend time there, allowing them to meet other service users and members of staff. Care plans are then formulated almost immediately, using all available information, once a service user moves into the home. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs had been identified and were being met. Health needs were met through a variety of external and internal health professionals, thus promoting service users to maintain positive optimum health. Medication systems are robust and safeguard service users health and safety. Service users are treated with respect and courtesy, with their privacy being upheld at all times. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Inspector viewed a sample of care plans. These were detailed, clear and demonstrated the service users health, social and personal care needs. All care plans are updated on a monthly basis and the Lead Nurses monitor the care plans to ensure they are relevant to the service users needs. The care plans highlight how staff need to support and encourage service users to maximise their independence and maintain positive health and include details of service users likes, dislikes and interests. Risk assessments were also viewed and these were detailed and up to date. These assessments cover a wide range of areas such as risk of falling, manual handling, risk of pressure sores and nutritional risk assessments. These are updated on a regular basis. Health needs, as noted above, were clearly outlined on care plans. The home does not currently have any service users with pressure sores. Where needed professional advice is sought if a service user has a particular health need. The Registered Provider informed the Inspector that the local GP comes to the home on a regularly basis to check on all of the service users. In addition, the home employs a Physiotherapist on a full time basis and they were seen working with a service user. This particular service user told the Inspector that their mobility and flexibility had greatly improved since having daily excerises. The Physiotherapist has also shown members of staff some of the excerises that they can perform safely with service users to ensure the mobility and flexibility of service users is maintained every day. Other health professionals also visit the home such as dentists, chiropodists and opticians. Health appointments or visits to the hospital are recorded so that staff are aware of any action to be taken or ongoing health needs. Service users are weighed on a regular basis to ensure staff can monitor and respond to any changes. The Inspector viewed the medication systems in place at the home. Controlled drugs are stored in a separate locked metal cabinet and are counted and recorded, in a separate controlled drugs register, at handover times during the day. The medication trolley is cleaned out and thoroughly checked once a week. The home does not keep an over stock of medication. The contract was viewed for the disposal of medication. Only nurses administer medication and they receive ongoing updates and refresher training regarding medication at regular intervals throughout the year. Samples of medication administration records were viewed and these had been completed correctly. The Inspector counted some samples of medication and these were all found to be correct. Where medication is stored in a small fridge the temperatures had been taken on a daily basis. Medication stored in the fridge had dates of opening written on them. The CSCI has not been notified of any medication errors occurring. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 12 Personal care tasks are carried out in private and where service users share a bedroom there is a screen to offer privacy. Service users stated they always receive their own clothes from the laundry room and that staff are respectful towards them at all times. Service users have access to a telephone, whilst some have their own personal mobile phones. Staff are aware of service users who choose to be in their bedrooms and are conscious of those service users who like their bedroom doors to remain open. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social activities are available and offer stimulation and variation to service users. Visiting is encouraged to promote social relationships for service users. Service users are encouraged to make choices and decisions about their lives. Meal provision and mealtimes are well managed and provide service users with a diet that meets their preferences and health needs. EVIDENCE: The home has recently employed an activities co-ordinator to offer group and individual activities. The Inspector met with this member of staff to ascertain their role within the home. The activities co-ordinator had arranged the previous week for a small group of service users to go out on a day trip and have a picnic. Service users commented positively on this day trip. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 14 The activities co-ordinator is in the process of exploring external people to visit the home to provide entertainment and occupation, such as the local school visiting to sing Christmas carols to the service users. An entertainer has already been booked for the Christmas period. In addition people from the Princes Trust are also visiting the home to provide an activity. The activities co-ordinator is keen to offer a variety of activities to suit the individual needs of the service users. A quiz took place on the day of the inspection and service users informed the Inspector that the new activities and trips out offer them variation to their day. The Inspector spoke with the Manager Designate regarding increasing the hours the activities co-ordinator works to ensure all service users benefit from their role within the home, she confirmed that this would be looked into. Members of staff also offer activities to maintain service users interests and to offer social interactions throughout the day. Some service users attend temples with family members or members of staff. Family contact is as frequent as families and service users want it to be. Visitors can see service users in their bedrooms or in communal areas. One service user was in India with family members for a holiday. Staff stated that wherever possible service users are encouraged to make choices regarding their lives. Those service users who are able to, manage their own finances. Within the home’s capabilities, service users can bring in their own personal possessions when they move into the home. The Inspector observed lunchtime and saw staff assisting some service users with feeding. This was carried out in a sensitive and respectful way. Lunchtime was unhurried and staff supported service users where necessary. The food viewed looked tasty and inviting and the Inspector sampled the food and found it to be fresh and of a high standard. Service users spoke highly of the changes, as there is a different member of staff currently providing lunches and suppers, in the meal provision and stated they had several meal choices each day. One service user, who has lost weight, said it was due to the healthy salads and healthy meals now offered to them. The Inspector met with the cook who was enthusiastic about trying new meals in order to provide variation and to meet individual service users preferences. Currently meals are planned over a four-week period and any alterations are noted along with the meals individual service users have eaten. Where possible fresh produce is purchased and special diets are catered for. The cook is aware of the service users who require pureed or soft food and seeks to meet the differing needs. Overall the kitchen, although small, was clean and tidy. Fridge and freezer temperatures had been taken daily and were within an appropriate range. Food opened and stored in the fridge had dates of opening written on them. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is available for service users and family members and service users felt confident that their comments would be listened to and acted upon. Systems are in place for the protection of vulnerable adults. EVIDENCE: The Inspector viewed the complaints book and found there had been no complaints since the last inspection. The CSCI have not directly received any complaints. The Inspector reminded the Manager Designate to make the complaints procedure visible within the home. The Manager Designate informed the Inspector that all service users have a copy of the Service Users Guide, which has details of the complaints procedure. Those service users asked, stated that they would speak to Management if they had any comments or concerns. The majority of service users felt their complaints would be listened to. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 16 There has been no protection of vulnerable adults, (POVA) concerns or investigations. Training is offered both internally and externally on this subject. The Manager Designate had attended training specifically designed for Managers who have to manage POVA allegations or concerns. Overall those staff asked knew how to respond if they had any POVA concerns. The Inspector reminded the Manager Designate to ensure staff know who to report POVA concerns to, including reporting concerns to the Local Authority’s Safeguarding Adults co-ordinator. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 17 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, 24 & 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users live in a well maintained home that is safe and inviting to live in. Service users bedrooms enable them to have the privacy and personal items around them to relax in. Overall the home was clean and hygienic. EVIDENCE: The Inspector carried out a tour of the home. The Manager Designate has been updating the communal areas making them feel more welcoming and homely. The walls had been painted and pictures and plants had been introduced. The Inspector noted there were some photographs of service users in the entrance hall. The next major piece of work is to look at installing a walk in wet room on the ground floor. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 18 This would enable service users to have a shower easily, with the assistance of staff. One service user had asked for their bedroom to be painted a particular colour and this was carried out to their satisfaction. The garden is small but had been maintained well, with plants in the border areas. One service user stated they were keen to do some gardening if their mobility increases. The Inspector viewed a sample of service users bedrooms. These were mainly single rooms, those that were double, have screens to offer privacy. These rooms were clean, bright and individual. Service users had brought in some personal possessions to make their rooms more individual. Asian service users had cultural television programmes offered to them in their bedrooms and were seen to be watching programmes in their first language. Staff asked, confirmed they receive health and safety, including infection control training. The Inspector also met with a housekeeper, who was carrying out laundry duties. They had attended infection control training and described the procedures for washing soiled items of clothing or bedding, including using red bags to minimise the spread of infection. The washing machine has a sluice cycle on it. Service users clothes are labelled to avoid any items going missing and those service users asked said they were happy with the laundry facilities in the home. The home was clean and odour free at the time of the inspection. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met through sufficient numbers of staff working in the home. Service users are supported in a safe way by staff that have the necessary qualifications and/or experience. The shortfalls in the staff employment files need to be addressed in order to fully protect and safeguard the service users. Staff receive regular, varied and detailed training in order to be confident and competent in the work they do and the support they offer to service users. EVIDENCE: The home currently has no staff vacancies. The Manager Designate has been ensuring the staff team receive training and supervision on a regular basis and so has not had any student/adaptation nurses working in the home for a short period of time. There is a suitable mix of qualified and unqualified members of staff. There are more staff working in the morning to meet the needs of the service users. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 20 There are two housekeepers, who clean the home and carry out laundry tasks, and between them they work seven days a week. The Inspector viewed the rota to ensure sufficient numbers of staff work at all times. The Manager Designate is aiming for all unqualified members of staff to gain an NVA qualification or equivalent. Currently the home is just meeting its target for 50 of unqualified members of staff to obtain an up to date relevant qualification. Samples of staff employment files were viewed. These contained completed application forms, Criminal Record Bureau checks, employment history and two references. On one file the health declaration had not been signed and there was not a recent photograph of the member of staff. A requirement was restated for staff employment files to contain all that is required in Schedule 2 of The Care Homes Regulations 2001. The Inspector viewed training and the induction training for staff. The home records the induction both qualified and unqualified members of staff work through. This includes familiarising themselves with the home’s policies and procedures, along with shadowing members of staff. Unqualified members of staff also work through the Skills For Care induction programme. The Manager Designate stated that within four weeks of starting work in the home new members of staff attend basic life support training and moving and handling. Training is seen as a high priority in the home and every fortnight a trainer visits the home to offer a variety of in house training to staff, covering a wide range of topics. Some nurses are currently studying a course to learn how to take bloods from service users. The home is also looking into offering training and information on dementia. The cook has attended food hygiene courses and all members of staff, including housekeepers attend the training courses to ensure all staff have the knowledge and information they need to carry out their jobs effectively. In addition, care staff and nurses have to present a topic to the main staff team on a regular basis, subjects include reporting an accident, care plans and confidentiality. The Manager Designate told the Inspector that they decide on the topic and give this to the individual member of staff. This is seen as a way to encourage staff to become familiar in presenting a subject and to be aware in depth of the topics they are talking to other members of staff about. Staff asked were happy with the training that is offered to them. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a Manager Designate who is fully aware of their role and responsibilities within the home. A summary of the reviews and quality checks that are carried out needs to be developed and be available for inspection and service users. Health and safety records are up to date and protect service users health and welfare. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Manager Designate is familiar with the running of the home and is in the process of applying to become the Registered Manager. They have been studying for an NVQ level 4 and hope to complete this qualification within the next two months. The Registered Provider is also in the process of studying for this qualification. The Manager Designate has suitably qualified lead nurses who offer guidance and supervision to other qualified nurses and external nursing staff offer the additional support and advice that is needed as the Manager Designate is not a qualified nurse. The Manager Designate is aware of the need to undergo periodic training and wherever possible attends the training that is offered to the staff within the home. This also enables her to monitor the quality of the training provided. The home has a variety of quality assurance systems in place to review the running of the home and to identify areas that need improving. Monthly Regulation 26 visits are carried out and reports are forwarded on to the CSCI. An external organisation also visits the home once a year and checks various aspects of the home and complies a report. The Manager Designate carries out an internal inspection every three to four months and this looks at the previous CSCI inspection report and other important documents such as care plans and service user’s files. The Manager Designate also views the CSCI website for information and details relating the care and running of the home. Finally questionnaires are also given to service users and family members. The Inspector acknowledged that there were sufficient procedures in place to monitor the home and to improve areas. However there was not an overall summary of the work that had been carried out along with showing the future plans and improvements the home is aiming to achieve. This summary must be devised and be made available for inspection and for service users to ensure they are aware of the work the home has been undertaking to improve the quality of life for the service users. A requirement was made for this to be addressed. Currently the home does not manage service users finances. Although this might change regarding one service user who can no longer take care of their personal monies. The home is looking into how this can be arranged. Therefore the Inspector did not have any service users personal finance records to view or personal monies to count. The majority of service users either look after their own money or have family members who take care of this area. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 23 Servicing records were viewed at random. The Gas Safety, testing for Legionella, servicing of the fire equipment and the Portable Appliance testing were all up to date. Water temperatures had been taken in all areas of the home and were within an appropriate range. The home is having a second water tank fitted to increase the pressure flow. Fire drills had been carried out at regular intervals and with different members of staff. The Inspector discussed with the Manager Designate whether full evacuations take place. Usually this is done with the assistance of the local fire brigade and not with members of staff. The Inspector made a strong recommendation for the home to carry out a full evacuation with all service users leaving the building. This will then enable the Manager Designate to be confident that should a fire occur then the risk to service users and others is minimised. The Manager Designate stated this would be carried out as soon as possible and recorded once it has taken place. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 24 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 25 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 OP29 Regulation Schedule 2 Requirement Each staff employment file must contain a medical declaration that is signed by the member of staff and a recent photograph. These must be available for inspection. (Previous timescales 28/02/06 not met) Timescale for action 06/11/06 2. OP33 24(2) A summary of the reviews the 31/01/07 home has carried out, including any relevant comments from service users and family members must be developed and be made available for inspection and service users. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 26 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 OP38 Good Practice Recommendations It is strongly recommended for the home to carry out a full evacuation at certain times throughout the year to ensure staff know the procedures and length of time it could take to fully evacuate the home. This type of evacuation should be recorded along with any relevant comments. Beacon House Nursing Home DS0000010965.V311251.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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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