CARE HOMES FOR OLDER PEOPLE
Beaconview Kiln Lane Skelmersdale Lancashire WN8 8PW Lead Inspector
Val Turley Announced Inspection 24th October 2005 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 Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 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.V251952.R01.S.doc Version 5.0 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 725682 Lancashire County Care Services Mrs Margaret Sutcliffe Care Home 35 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (28) of places Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The home is registered for a maximum of 35 service users to include: Up to 28 service users in the category OP (Old age, not falling within any other category). Up to 7 service users in the category of DE (Dementia). The service should, at all times, 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 which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. The matters detailed in the attached schedule must be completed within the stated timescales. 23rd May 2005 5. 6. 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 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 DS0000034114.V251952.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in October 2005 by one regulatory inspector. The inspection involved discussion with service users living at the home, visiting relatives and also discussion with and observation of the staff working there, an examination of records, policies and procedures and a tour of the premises. 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?
Since the last inspection the home had produced a Statement of Purpose and Service User Guide for the benefit of service users and their representatives. A new care plan format had been introduced which included all of the relevant detail and allowed the needs of the service users to be detailed. The care plans indicated that community health professionals provided additional support to
Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 6 service users where appropriate. The homes management of medication had improved with staff following policy procedures and therefore safeguarding the interests of the service users. The home had produced some guidance for staff to follow should they become aware of a suspicion of or an allegation of abuse be made ensuring that the service users are adequately protected. 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 DS0000034114.V251952.R01.S.doc Version 5.0 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 Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 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): 1 and 3 The homes Statement of Purpose and Service User Guide gave a clear outline of the homes facilities and services. Some amendments needed to be made to ensure that correct information is provided. The pre-admission process was in sufficient detail to ensure that prospective service users supports needs are fully assessed before admission. EVIDENCE: The home had a Statement of Purpose and Service Users Guide in place. These included all of the required detail although some amendments needed to be made. The documents referred to the Inspection Unit rather than the Commission for Social Care Inspection and the contact information for the Advocacy Service was inconsistent. The section that dealt with complaints should be amended to make it clear that complaints can be made directly to the Commission for Social Care Inspection. No new service users had been admitted since the previous inspection so it was not possible to fully assess National Minimum Standards.3, however documentation at the home suggested that the home had an appropriate preadmission process in place ensuring that the home determined whether they were able to meet the needs of the service user.
Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 9 Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 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 and 9 Care plans were detailed and helped ensure that staff were able to provide appropriate support to service users and meet their health care needs. Robust medicines management policies were in place, however some additional work needed to be undertaken to ensure the safety of the service users. EVIDENCE: These standards were partly assessed to ensure that the requirements and recommendations made at the previous inspection had been acted upon. The home now had a new care plan format in place, which included all of the relevant detail. As the care plans had only recently been developed, it had not been appropriate for them to be reviewed. A questionnaire returned by one relative indicated that they were satisfied with the care provided to their family member. A visitor on the day of the inspection confirmed that the care provided was good and that staff were very approachable and would listen and act on any concerns expressed by relatives. There was evidence within the care plans that the support staff involved community health professionals appropriately to help ensure that the health needs of the service users were addressed. In respect of the management of medicines within the home, improvements had been made since the previous inspection. There were however some remaining areas of concern. The medication trolley was not secured to the wall
Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 11 and the receipt of medications into the home was not recorded. It was recommended that the home acquire a copy of the Royal Pharmaceutical Society of Great Britain guidance for the management of medication in care homes to enable staff to be more aware of good practice issues. The homes system for prompting medication reviews must be reviewed to ensure that this is undertaken safely and that GP’s are involved appropriately. Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Care plans acknowledged service users preferences and routines and service users were supported appropriately by staff to achieve these. EVIDENCE: The care plans for each of the service users included the service users preferred daily routines and information regarding their individual interests and hobbies. Discussion with one member of staff indicated that she was aware of the need to understand and appreciate the individual needs and preferences of the service users. One service user spoken to had a preferred daily routine that the staff were aware of and he was supported to follow. The service user praised the care that the staff provided. From observation of the staff and discussion with him it was clear that they had an understanding of him as an individual and supported him appropriately. The Service User Guide included information for visitors. On the day of the inspection, visitors were observed to be relaxed and comfortable, having a good relationship with support staff. A service user confirmed that visitors were able to visit at any reasonable time. The home had good policies in place in respect of encouraging service users to maintain their independence as far as possible. Information was available for both service users and staff regarding the possible involvement of the local advocacy service and the contact details were available. It was noted that
Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 13 service users were able to bring personal possessions with them into the home to personalise their rooms and assist in the transition to residential care. The home had a rotating menu in place, which offered a range of meals to service users. The residential unit open at the time of the inspection had its own small kitchen, which enabled snacks and drinks to be prepared at any time. The manager stated that alternatives to the menu were always available and a member of staff confirmed this. Information from staff indicated that specific support was provided at meal times where this was appropriate and individual preferences were attended to. Service users spoken to were complimentary of the meals provided. Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 14 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 and18 The home had a detailed complaints policy in place, which would ensure that all complaints would be acknowledged and investigated, however this information was not provided accurately within the statement of purpose and service user guide, therefore potentially denying service users of all potential avenues of complaint. The homes policies and procedures for the Protection of Vulnerable Adults was not robust enough to ensure that service users are safeguarded from harm. EVIDENCE: Both of these standards were partly assessed. Although the home had a comprehensive complaints policy and procedure in place, information included within the Statement of Purpose and Service User Guide needed to be amended to ensure that the information provided in these documents is consistent and correct. Since the previous inspection the home had produced some guidance to be followed should an allegation of abuse be made. This should be further extended to make it clear that staff should not make any attempt to investigate any serious allegation themselves. Training must be undertaken by all staff in the Vulnerable Adult Procedures to ensure that they have a full understanding of their responsibility to ensure the safety and well being of the service users. The homes policy that addresses the management of physical and/or verbal aggression did not include any guidance on the involvement of any health care professionals in the development of management strategies, although the registered manager was aware that these professionals should be involved.
Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 15 The policy must be amended appropriately to ensure that service users are protected. Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 None of these standards were assessed at this inspection. EVIDENCE: Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 17 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): 30 Although the training records indicated that the staff team had a range of knowledge and skills, additional detail should be recorded to enable staff training to be planned and updated more effectively EVIDENCE: The staff team was well established with no new members of staff having been appointed since November 2003. Consequently all staff had attended a number of training courses. An examination of the training matrix indicated that the staff team had a range of skills and knowledge. The training matrix did not make it clear when staff had attended individual training courses and therefore did not flag up a need for training to be updated. The registered manager stated that a new training matrix was being developed which would include this information. The manager also stated that training in moving and handling and food hygiene had been arranged for those staff who needed an update. Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 18 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): 35 and 38 Policies and procedures in place at the home in respect of the management of service users monies were appropriate and safeguarded the interests of the service users. The registered manager ensured as far as possible the health, safety and welfare of service users and staff. EVIDENCE: Policies and procedures in place in respect of the management of service users monies were appropriate and followed by the staff team. All transactions made on behalf of service users were recorded and monies were stored securely to safeguard the interests of the service users and balances. The home had a range of policies and procedures in place to ensure as far as possible that the safety of all service users and staff was maintained. All equipment and systems was maintained and serviced appropriately. Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 19 The home had continued to provide a relaxed and comfortable environment in spite of the building work taking place and any risks to service users, staff or visitors had been minimised as far as possible whilst the work was underway. Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 20 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 21 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) 17(1)(a) Sch3(I) 13(2) 13(2) Requirement The registered manager must make keep a record of all medications received into the home. The medication trolley must be secured to the wall. The homes system for prompting medication reviews must be reviewed to ensure the safe administration of medication. All staff must receive training in the Protection of Vulnerable Adults. Timescale for action 30/11/05 2 3 OP9 OP9 30/11/05 30/11/05 4 OP18 13(6) 31/03/05 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 Refer to Standard OP1 OP16OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should contain consistent in respect of the contact details of the Advocacy Service. Information concerning the complaints procedure within the Statement of Purpose and Service User Guide should
DS0000034114.V251952.R01.S.doc Version 5.0 Page 22 Beaconview 3 4 5 OP9 OP18 OP18 6 OP30 be amended to make it clear complaints can be made at any stage to the Commission for Social Care Inspection. The home should obtain a copy of the Royal Pharmaceutical Society of Great Britain guidance for care homes. The homes guidance for staff regarding the action to take should a suspicion or allegation of abuse be reported should be strengthened giving clearer guidance. The policy, which deals with the management of challenging behaviour, should be strengthened to include the need for the involvement of health care professionals in the development of any management strategy. The homes training matrix should be more detailed to enable the staff teams training needs be identified more easily Beaconview DS0000034114.V251952.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Chorley Local Office 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
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