Inspection on 23/05/05 for Beaconview

This inspection was carried out on 23rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beaconview 18/10/07

Beaconview 21/12/06

Beaconview 24/10/05

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 Della Lovell Unannounced 23 May 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beaconview Address Kiln Lane Skelmersdale Lancashire WN8 8PW 01695 724913 01695 724913 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Lancashire County Care Services Mrs Margaret Sutcliffe Care Home 35 Category(ies) of DE - Dementia (7) registration, with number OP - Old age (28) of places Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 35 service users to include:1. Up to 28 service users in the category OP (Old age, not falling within any other category). 2. Up to 7 service users in the category of DE (Dementia). 3. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 4. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 5. The matters detailed in the attached schedule must be completed within the stated timescales. Date of last inspection 18 October 2004 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 twenty- eight older people and seven older 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. Beaconview is currently undergoing major refurbishment and building work with an expected completion date of December 2005. It is expected that the numbers of service users to be accommodated at Beaconview will be increased. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one full day in May 2005. The pharmacist inspector was also present and undertook an inspection with regards to the homes policies and procedures for dealing with medicines. During the inspection discussions took place with the registered manager, staff members and service users. Comments from service users were positive about the service they receive from the home and staff said they felt supported by the management team at Beaconview. A number of records and documents were examined as part of the inspection process. Beaconview is currently undergoing a major refurbishment and building programme, seventeen service users remain living at the home during this time. However no new service users are being admitted to the home until work is complete. A full tour of the building was undertaken and appropriate measures where in place to minimise any disruption to the home and service users. What the service does well: What has improved since the last inspection? Beaconview is currently going through major change and the manager is fairly new to her role as the registered manager. However since the last inspection the manager has introduced supervision for staff, which is well documented and ongoing. Over 50 of care staff now hold an NVQ Level 2 in Care Qualification. The planned programme for refurbishment and building works is well underway and the manager is maintaining to manage the home effective and efficiently with little disruption to the service users. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 6 One service user told the inspector that that they were looking forward to to their new room at Beaconview. 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. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 There was no Statement of Purpose and Service User Guide available on the day of the visit to ensure that service users and their family have sufficient information about the service the home provides. EVIDENCE: At the previous inspection the statement of purpose and service users guide did not reflect the registration category of the home, an action plan was submitted to the Commission to confirm that this would be actioned as a matter of urgency however the statement of purpose / service user guide was not available on the day of this visit. The Home is currently going through a major refurbishment and building programme, no new service users are being admitted to the home during this time, however the remaining service user and their family should have information which is contained within the service users guide. The home must ensure that all new service users admitted to the home in the future receive a copy of the service users guide. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Care plans do not provide adequate information for staff to ensure that service users needs are identified and therefore met. The service users were supported by staff in such away as to promote and protect service users dignity and independence. Robust medicines management policies and procedures were in place, however all staff must adhere to these in order to protect residents. EVIDENCE: Individual care plans are available for each service user but it was unclear to whether or not the care plans had been developed from the local authorities assessment or from the home assessment. Not all aspects of health, personal and social care needs were identified and the care plans did not contain written instruction for staff on how the assessed need would be met. One care plan did not contain information on the treatment a service user was receiving for a pressure sore and another care did not provide instruction for staff on a service user being cared for in bed. Discussion with staff and the management team suggested that the care needs were being met even though there was a lack of information on the care plan. This approach was dependent on informal communication between staff members and the staff’s knowledge and understanding of the service user. If Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 10 this informal system breaks down the service users would be at risk of not having their needs met. Information with regards to service users care was reviewed on a regular basis however care plans are not up dated to reflect the current needs of the service users. Both the management team and the care staff spoke about service users in a sensitive caring way and understood about the need to respect dignity and privacy and promote independence. Medication records were generally clear and accurate, however, where staff had amended Medication Administration Record charts it was difficult to ascertain what had been administered and the current dose intended. Handwritten annotations should be checked and witnessed to avoid errors. Appropriate storage facilities were available, and will be improved after planned refurbishment. Better use of existing medication cupboards should be made. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 12,13,14 and 15 were not assessed at this inspection. EVIDENCE: Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home had a detailed complaints procedure in place, which ensured that all complaints would be acknowledged and investigated. The homes policy and procedure for the Protection of Vulnerable Adults was not robust enough to ensure that service users are safeguarded from harm. EVIDENCE: The home had a detailed complaints procedure in place. Complaints were recorded on a separate proforma, which included the details and action taken by the home. Records showed that service users were aware of how to complain and all complaints had been appropriately managed by the home. Although the home had a copy of the No Secrets in Lancashire Document, a written procedure for responding to allegations of abuse was not available. The manager and staff spoken to were able to confirm the correct procedure they would follow for reporting allegations of abuse. A number of incidents had been recorded relating to a service user with aggressive behaviour. These incidents involved staff members and a service user. There was no clear written procedure or strategy in place to ensure that further incidents do not take place and that service users are safeguarded from harm. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Although Beaconview is currently undergoing a major refurbishment and building programme, comprehensive risk assessments were in place to ensure that service user’s continue to live in a safe environment. EVIDENCE: The home was undergoing major refurbishment and building work. Seventeenservice users remain living in the home whilst the work is underway. There was very little evidence once entering the home that extensive building work was taking place. One service user said that they were looking forward to the new home and a new room and staff said that on days when noise may be high planned trips out had taken place. One service user was reading a book in the entrance hall and other service users were watching television in the lounge. All service users were relaxed and the atmosphere was calm. Although the furnishing and fitments were worn the home was clean and tidy. Extra measures had taken place in the kitchen to ensure that food preparation areas are free from any dust. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 14 A schedule of works is available which ensures that the changes are on target and that there is as little impact or intrusion as possible for service users. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 &29 The homes recruitment policies and procedures ensure that services users are safeguarded. Staffing numbers are sufficient to meet the needs of the service users and staff are provided with training to ensure that they are competent to do the job. EVIDENCE: There has been no new staff recruited to work at the home since the last inspection. The manager said that staff would not be employed with out the appropriate checks in place. Staffing level were sufficient for the numbers of service users living at the home. One-service users said that she was happy living at the home and other service users seemed content and at ease with staff members. A number of staff had completed their NVQ Care Qualification and some staff were working towards their qualification. The manager said that over 50 of the staff in the home have now completed the NVQ in Care. The staff team at Beaconview have many years experience of working with older people in residential care. A training matrix was kept by the home to ensure that staff are provided with mandatory training. A number of staff were ready for their certificates in moving and handling and food hygiene to be updated. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 and 36 The home was well managed and run in the best interests of the service users. EVIDENCE: The registered manager is fairly new to the post but has many years experience of caring for older people in a residential setting and has previous supervisory experience. The manger is currently managing the major refurbishment programme taking place at Beaconview efficiently and effectively. Service users safety and welfare are the manager’s main priority. A service user’s meeting had been arranged to ensure that service users could discuss items relating to the home, relatives were kept up to-date with the plans and progress of Beaconview. One service user told the inspector that the staff were very good and that they were happy living there. The manager said that relatives were involved in any temporary room changes and the movement of their relative’s belongings. Staff supervisions had taken place and the manager meets on a regular basis with the area manager. Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x x 3 x x Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4(1) c Schedule 1 Requirement Timescale for action 30/6/05 2. 1 3. 1 4. 7 5. 8 The statement of purpose and service user guide must be amended to include all information as outlined in the regulations. (Previous timescale of 31/12/05 not met) Reg. 8. The registered person must Schedule amend the statement of Purpose 7 Part to reflect the current registration 6(a)(c)(Re conditions for Beaconview. gistration) (Previous timescale of 31/12/05 Regulation not met) s 2001) 5(2) The registered person must ensure that a copy of the service users guide is supplied to each service users and to the Commission for Social Care Inspection. 15(1) The registered person must ensure that the care plan provide written instruction in accordance with each identified assessed need and the action required by care staff to meet the needs. (Previous timescale of 31/12/04 not met) 15(1)(2) The registered person must ensure that all health needs are identified on the assessment / F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc 30/6/05 30/6/05 30/6/05 30/6/05 Beaconview Version 1.30 Page 19 6. 9 13(2) 17(1)(a) Sch3 (i) 7. 8. 9 18 13(2) 17(1)(a) Sch3 (i) 13 9. 19 23(1a)(2a ) care plan providing clear information and instructions on how these are met by the home. (Previous timescale of 31/12/04 not met Records must be kept of all medicines leaving the custody of the home e.g. passed to residents for self-medication, relatives, hospital admissions etc. The administration of creams and other external products must be recorded. The registered person must ensure that a written procedure is drawn up for recording and reporting suspicion or allegation of abuse. The registered person must ensure that that following refurbishment the home will be suitable for it’s stated purpose. 30/6/05 30/6/05 30/6/05 2005 10. 20, 23,19,24 16(2) 23(2)(n) 18(i) 11. 30 18(c ) (i) The registered person is required 2007 to ensure that the home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of service users The registered person must 31/12/05 ensure that staff are updated with regards training in moving and handling and food hygiene. 12. 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 Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 20 1. 2. 19 9.3 3. 9.4 4. 5. 9.5 9.7 6. 7. 9.10 The registered person should ensure that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999 Criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all service users prescribed such items.A second member of staff should witness all hand written annotations on Medication Administration Record charts. Medicines should be stored in the available metal medicines cabinet rather than in adapted kitchen cupboardsMedicines must be stored at the appropriate temperature. A record of temperature must be maintained for all areas where medicines are kept (fridge should be monitored daily) Controlled Drugs should be stored in Controlled Drug cabinet rather than on the trolley Manufacturers Patient Information Leaflets should be available for medicines in the custody of the homeThere should be a ‘signature’ list for staff authorised to administer medication There should be a formal system for prompting medication reviews in line with National Service Framework for Older People Beaconview F57 F08 S34114 Beaconview V226319 230505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley, PR7 1NW 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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