Inspection on 21/12/06 for Beaconview

This inspection was carried out on 21st December 2006.

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 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

Beaconview 18/10/07

Beaconview 24/10/05

Beaconview 23/05/05

Beaconview 18/10/04

Beaconview 29/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Beaconview Kiln Lane Skelmersdale Lancashire WN8 8PW Lead Inspector Phil McConnell Unannounced Inspection 09:30 21st & 28 December 2006 th 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 Beaconview DS0000034114.V322582.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. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaconview Address Kiln Lane Skelmersdale Lancashire WN8 8PW 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) 01695 725682 01695 555834 Lancashire County Care Services Mrs Margaret Sutcliffe Care Home 44 Category(ies) of Dementia (16), Old age, not falling within any registration, with number other category (28) of places Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 44 service users to include: Up to 28 service users in the category of OP (Old age, not falling within any other category). Up to 16 service users in the category of DE (Dementia). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines that may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 24th October 2005 2. 3. Date of last inspection Brief Description of the Service: Beaconview is a purpose built home situated in Skelmersdale. The accommodation is on two floors and is serviced by a lift. It is situated near to local shops and facilities. The home is one of a group of homes that is managed by the Lancashire County Care Services. Accommodation is provided in single rooms in three units for forty-four older people, including sixteen people with care needs associated with a diagnosis of dementia. There are a total of nine communal areas one of which is a designated smoking lounge. Some significant refurbishment improvements have been made to the establishment since the last inspection visit. The present rate of charging is between £310.50 and £350.00 Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The assimilation of information was used to assess the key standards that are identified in the National Minimum Standards for older people, including: 53 service users’ survey forms and 10 relatives comment cards returned to the commission for social care inspection (CSCI). Generally the majority of the returned survey forms were positive. Other information included the pre inspection questionnaire completed by the registered manager and an unannounced inspection visit to the service, which covered two full days the 21st of December and an announced return visit on the 28th of December 2006. During the visit to Beaconview, four service users’ files were examined, including the last person to go and live at the home. There was the opportunity to speak to a number of the service users, some relatives and visitors including, a district nurse, the homes hairdresser, the curate from the local Anglican Church and a lay minister from the local RC church. (Both visit on a regular basis to conduct services). Four staff files were also examined, including the last person to be employed by Lancashire Care Services and their files contained all of the required information to meet the national minimum standards. The registered manager was available throughout both days of the inspection visit. On the first visit the area manager was visiting the home and stayed for the majority of the day, on the second visit the acting general manager also visited in the afternoon. There was also the opportunity to have conversations with other staff members including, the office administrator, care assistants, both of the homes cooks, the maintenance man and the four residential care officers who are part of the management team. The providers’ policies, procedures and all other documentation including health and safety files and certificates were examined and found to be up to date and satisfactory. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The medication procedures need to be more robust in order to safeguard vulnerable people. (A pharmacist inspection has been carried out, with a number of requirements issued). Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 7 The medication training needs to be re-assessed and adjusted to ensure that all staff that have the responsibility for the administration of medication are satisfactorily trained and assessed as being competent. It would benefit both the cooks and service users if the homes two cooks had a weekly overlap, in order to discuss and plan menu’s, any specific dietary needs and best work practice matters (See standard 15). The laundry facilities need to be re-examined to ensure that the best possible system is in place. This will help manage infection control and help prevent any potential cross infection. (The provider is seeking guidance from the Environmental Health Authority). There is a need to ensure that cupboards and rooms containing hazardous or harmful materials and equipment are kept locked, in order to protect and safeguard vulnerable people. The carpeting in Goldfinch unit (see environment section) can cause some confusion to people who have varying degrees of dementia. This potential health and safety risk could lead to vulnerable people having unnecessary and avoidable falls. It would be good practice to have un-patterned carpets in areas where people with high dependency needs are being cared for. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission assessment process is thorough, helping to ensure that individuals’ needs are identified and that they can be met by the home. EVIDENCE: Four service users’ files were examined including the last person to be admitted to Beaconview and all of their files contained full and relevant assessment documentation including: pre-admission assessments with incorporated care plans (which are reviewed monthly) terms and conditions of residence and a list of belongings on admission. One relative said that she was involved in the assessment process for her mother and commented “We went to 10 other homes before we came here. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 10 This was by far the best, it’s been absolutely fantastic” and went on to say “none of my family can believe how wonderful it is”. A visiting district nurse said, “as a nurse I visit here nearly every day, we are looking for a place for my Nan and I have recommended Beacon view”. Some of the comments from service users were, “I got all the information I needed before I decided on the home” and “my family and I received all the information before I decided to come and live here”. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good care plans and risk assessments are in place, helping to ensure that individual’s needs are being appropriately met. The home works in partnership with other agencies to ensure that service users’ health needs are fully assessed and addressed. The recording and administration of medication, including controlled drugs is not satisfactorily carried out, this could cause potential harm to service users. Equality, dignity and respect is actively and positively demonstrated in the way that care is provided. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 12 EVIDENCE: The care plans examined were found to be up to date, containing relevant information with clear guidance on how to provide individual personal care and how to meet a person’s health care needs. The service users’ files also contained individual nutritional assessment records and falls risk assessments. Individual information was also available with regard to service users’ specific health needs and there was evidence that, hospital appointments, GP’s appointments and other treatments and consultations with other health professionals had been carried out. There is a specific checklist for each unit including, Doctors visits, District nurse visits, any concerns and a follow up/action column. This helps to demonstrate that people’s health needs are monitored and treated correctly when necessary. The care plans are reviewed monthly, helping to demonstrate that individuals’ health and personal care needs are regularly monitored and assessed, in order to ensure that they are adequately provided for. A record was observed of all of the service users who have had a recent influenza vaccination and there were details of some people who had refused and the reason why. During the inspection visit a district nurse was visiting a service user who had been confined to bed and the care assistant asked if a bed-table could be acquired for this person, within the next hour one was delivered to the home from the local loan stores. This demonstrated the good links that have been established with other professionals and agencies. A comment from another district nurse was “We can tell that people are well looked after here and we have a good relationship with Beaconview”. There are contracts/agreements in place, for individuals wishing to take the responsibility for self-administering their own medication, and it was stated by the manager that “were possible service users are encouraged and enabled to maintain their independence in taking their own medicines”. Each of the units’ medication trolleys were securely fastened to the wall (previous requirement). The administration of medicines being given in Goldfinch unit was observed and found to be satisfactory. However, there were some concerns with the overall medication procedures within the home, particularly with regards to the recording and administration of controlled drugs. An immediate requirement was issued in respect of the administration of fenanyl medication to a service user. On the second visit it was observed that this particular issue had been addressed, with more stringent procedures having been put into place. A referral was made for a pharmacy inspection visit Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 13 to be carried out by a pharmacist from the commission for social care inspection (CSCI). (The pharmacist will issue a separate report) In observation throughout the visit, service users were treated respectfully and with dignity and some of the comments received were, “I could not wish for better attention that my father has been given, both medical and care” “my family and myself feel totally at ease now that our mother is being cared for by excellent and friendly staff” and “this is the most fantastic place, it’s just wonderful. The staff are unbelievable, from the welcome to the care that is provided”. A letter had been sent by a relative of someone who had lived at Beaconview and had recently died, part of the letter said, “The staff were faultless in their physical care of my mother, each and every one of them was prepared to go the extra mile”. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a number of varied activities, promoting stimulation and motivation to service users. Visitors are made welcome to the home, demonstrating that relationships with family and friends are maintained and encouraged. The meals provided are wholesome and nutritious, with the food menus providing a balanced diet, helping to promote a healthy eating plan for all service users. EVIDENCE: The home has a number of varied activities taking place on a regular basis including: art & crafts, sing-along, home cinema, movement to music, musical Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 15 memories with musical instruments, reminiscence activity, giant bat & ball, giant connect four (mainly for people with visual or physical impairments). There is also regular entertainment coming into the home and the opportunity for people to attend outside activities, with the homes notice board displaying forthcoming events, including a Christmas calendar of events, including a concert being held at the home and a pantomime advertised for the Southport theatre. One of the popular activities for 2006 were barge day trips and it was observed that dates for barge trips have been arranged for 2007. There was the opportunity to have brief conversations with two visiting representatives from local churches, a lay minister from the Roman Catholic Church and a curate from the Anglican Church and they said, “I visit regularly and the staff are excellent and are always ready to welcome me” and “the staff are very welcoming and are really good in the Goldfinch unit in the way they help and enable people” (Goldfinch is a unit for people who have higher dependency needs). There were books, magazines and daily newspapers also available within the home. The home has two hairdressers who visit on separate days on a weekly basis. One of the hairdressers commented, “I have a good relationship with most of the residents, I really enjoy coming here”. The home has an open house policy with visitors to the home being made welcome and service users are encouraged to maintain relationships with their families and friends. During both of the inspection / visits there was the opportunity to speak to service users’ visitors and they said, “You can visit at any time, morning, noon or night and you are always made welcome” “I usually visit twice a week and I am always made welcome” and “I couldn’t have been more pleasantly surprised and relieved at how wonderful Beaconview has been”. There was a choice of menus available, which were seen to be nutritious, varied and appetising. Some of the comments regarding the meals were, “We have very good food” “The meals are always very nice” “there is always a good variety to choose from” and one person wrote, “I have different dietary needs, because I have diabetes and the food is always good”. There was the opportunity to speak to both of the homes cooks, who have many years of experience between them. The cooks work independently of each other and a recommendation was made to the registered manager, that it would benefit the cooks and the service users if the cooks could have a weekly overlap, whereby they could discuss in more detail menus, individual service users’ specific dietary needs and best working practices. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough satisfactory policies and procedures are in place, helping to protect vulnerable people. Staff members are suitably and adequately trained, in order to manage any protection issues. EVIDENCE: The home had a comprehensive complaints policy and procedure in place, regarding the safeguarding and protection of vulnerable adults. There had been no complaints received since the last inspection, however there have been some reported notified incidents and allegations of abuse, which have been dealt with in a satisfactory, appropriate and acceptable manner in accordance with the national care standards requirements. In speaking to some of the service users and family members there was a general awareness of who to speak to if they had a concern or a complaint and they were also aware that the inspector for CSCI (commission for social care inspection) could be contacted if they chose to do so. Some of the comments Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 17 were, “my main concern is the care of my father and I have no complaints” and “I Have no complaints, everything is fine”. There was a thorough policy in place to deal with a suspicion or allegation of abuse and the staff had received training in the protection of vulnerable adults. The staff members who were spoken to were fully aware of the procedures to follow, if there was any suspicion or alleged abuse and would be confident in the process, highlighting that staff had been trained in the protection of vulnerable Adults. One person said, “If someone acted differently or became withdrawn, this maybe because the person is being abused in some way and I would know what to do”. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained, however some concerns were observed with unlocked doors, the laundry facilities and the inappropriate carpeting in the high dependency unit. The home was clean and decorated to a high standard, which gives a pleasant environment to live and work in. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 19 EVIDENCE: A full tour of the home was completed and throughout it was found to be of a good standard, it was clean, homely, and fresh smelling, comfortable and hygienic with a large fully equipped kitchen, which was clean, bright and practical with stainless steel cupboards and working areas. The fully equipped main laundry was situated away from the general living area, helping to effectively manage infection control, however there was a very small laundry situated in the upstairs Goldfinch unit, which was designed to be used for personal items of clothing and the larger items to be washed are transported in containers to the ground floor main laundry, this work practice could potentially cause some issues with regards to infection control. In discussion with the registered manager it was decided to make a referral to the environmental heath department in order to determine if this practice is acceptable. The home was found to be very well decorated, with all of the service users’ bedrooms demonstrating their own personality, containing individual’s own personal possessions, including photographs, ornaments and items of furniture, helping to demonstrate that people are encouraged to bring their own belongings into the home, helping to maintain familiarity and identity. The home is well furnished, with good quality furniture in the unit lounges and combined dining rooms. As already mentioned the home has been refurbished throughout to a very good standard with excellent quality carpeting throughout, however it was observed that the carpet in the Goldfinch unit with cream circles was causing some confusion to some of the service users with dementia. One person was observed trying to pick up what was thought to be bits of paper off the floor. This causes anxiety and distress and could potentially cause service users to have falls. A discussion took place with the registered manager and the area manager regarding the carpeting and the laundry situation. There was appropriate specialist equipment observed around the home, such as lifting hoists, passenger lifts and walking frames, thereby helping to ensure that individual needs are catered for, whilst independence is promoted. The cupboards in each of the units containing the electric meters and fuses were all unlocked. New locks were fitted before the second visit. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels are satisfactory and the staff team have sufficient skills and experience to provide an adequate standard of care to vulnerable people. The home has a rigorous recruitment process, which gives the confidence that service users are protected and safeguarded as much as possible. The training provided is generally very good, however there is a need to ensure that medication training is regular, robust and rigorous, in order to guarantee that vulnerable people are safeguarded and protected from harm. EVIDENCE: The staffing levels were examined and found to be adequate and satisfactory, to meet the needs of the people who live at Beaconview. Three staff files were examined and it was apparent that the files of the more recently employed staff contained more information than the staff who have been employed for a longer period. In discussion with the manager it was stated that all of the files are being updated, in order for them to have sufficient and up to date information. However there is a thorough recruitment process in place, with staff files containing evidence that Criminal Record Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 21 Bureau (CRB) checks had been carried out and staff are only employed on the satisfactory completion of these checks with two independent satisfactory references being obtained, thereby helping to ensure that service users are protected and safeguarded by having a robust recruitment and selection process. The home has a well-organised and concise training matrix in place, with dates in place for planned training. Because of the identified issues with the medication procedures (see standard 9) it is strongly recommended that training for the administration of all medication is readily available and regularly reviewed and updated accordingly. There is a detailed list of all the staff who have obtained the national vocation qualification (NVQ), with over 90 of the staff having achieved this award in level two and a number also having achieved level three. During the inspection visit the staff were observed demonstrating a caring, sensitive, dignified and respectful approach, with service users responding positively and it was evident that good relationships existed between service users and the care staff. One of the comments received from a service user was, “the staff look after you, they are all A1”and one relative said, “The girls are always willing to help in anyway they can and always make time for a chat”. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. (Standard 36 regarding supervision was also partly assessed) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and organised, ensuring as much as possible that service users receive a good quality service. The financial arrangements for residents were thorough enough to ensure that individuals’ finances were protected. The health and safety certificates were up to date, however the concerns with the medication procedures, fails to ensure that peoples’ health matters are not sufficiently promoted. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has over 13 years of experience in the care profession and she has been a registered manager for over 2 years. She is adequately qualified, having obtained the national vocation qualification in level 4 (NVQ) and has also been successful in obtaining the ‘registered managers award’. Beaconview has a management structure in place, which ensures that there is always the registered manger or at least one of the 4 residential care officers (RCO) on duty during the day. The service users’ financial records were examined and found to be well maintained and organised, helping to ensure that individuals’ finances are sufficiently safeguarded, thereby protecting vulnerable people. The home’s policies and procedures were examined and found to be up to date and satisfactory, helping to ensure that policies are kept up to date and relevant for the care and protection of vulnerable adults. The home continues to maintain the ‘Investors in people award’, which is an independent quality-monitoring organisation. In discussion with other staff members, there was a general opinion that the management is fair and approachable, some of the comments were, “The manager is brilliant” and “all of the management are approachable”. The formal supervision of staff appears to be a little disorganised, with some of the staff stating that supervisions are infrequent, one person said “I have only had one supervision in twelve months”. This was raised with the manager and an acknowledgement was given that some of the staff supervisions had not taken place as frequently as they should. An assurance was given that supervisions will be on a more regular basis. All inspection certificates were in place and up to date and correct, including: gas safety certificates, electric check certificates, fire extinguisher checks, lifting hoists and emergency lighting certificates and inspection records were available with regard to the testing of water temperatures. The manager was making a referral to the Environmental Health regarding the transportation of laundry from one floor of the building to another (see environment section). As previously mentioned a referral was being made to the commission’s pharmacy inspectors, regarding the concerns over the medication procedures. Beaconview DS0000034114.V322582.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 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 (2) Timescale for action The registered person shall make 21/12/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (Also separate pharmacist requirements have been issued) After consultation with the 28/02/07 environmental health authority, (Referral) make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. (Regarding the laundry situation) (a) All parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (c) Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. (Regarding the carpeting in Goldfinch). 31/03/07 Requirement 2 OP19 16 (2) (j) 3 OP19 13 (4) (a) (c) Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 26 4 OP30 18 (C) (i) Ensure that all staff that administer medication are appropriately trained, especially in the administration of controlled drugs. 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP19 OP36 Good Practice Recommendations The homes cooks would benefit from having an overlap during the week, in order to discuss and agree on menus and any specific dietary needs for the service users. Cupboards and rooms containing potentially hazardous or harmful materials and equipment should be kept locked at all times. The formal supervision of staff should be regularly carried out, in line with the recommended timescale, which is every 6 to 8 weeks. Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beaconview DS0000034114.V322582.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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