Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 10/01/07 for Beaconville Nursing Home

Also see our care home review for Beaconville Nursing Home for more information

This inspection was carried out on 10th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 makes good assessments of service users who are referred to them selecting those whose needs they can meet. They plan and review the care they provide on a regular basis communicating with and involving the service users relatives and advocates. The records they make are clear and informative reducing the likelihood of them not being used or understood. The Registered Manager has a good relation with her staff commanding their respect. Training that is undertaken by the staff is well focused and of a high standard that has the benefit of preparing the staff well to meet the needs of the service users. The premise has undergone constant but gentle change under the previous owners to improve the design to the benefit of the service users. This, it is understood, is to continue under the new ownership.

What has improved since the last inspection?

The Registered Manager told me that the home has looked at the quality of the meals provided and the choices of food and presentation. There is now a new menu with greater choice of meals both cooked and cold. The design of the communal space has improved with the building of a conservatory between the two lounges that does allow ambulant service users to wander safely within the confines of the ground floor area of the home. The Registered Manager has now completed the Registered Managers Award, National Vocational Qualification level 4. The Deputy Manager and one other Registered Nurse has also completed this award.

What the care home could do better:

The home achieves its aims and objectives. It does this in a calm controlled way. It also is progressively changing as it reacts to the quality assurance information it receives and also to new ideas and legislation. The inspector feels that they are continually performing well and have a clear understanding themselves about what their priorities are to achieve even more as time passes.

CARE HOMES FOR OLDER PEOPLE Beaconville Nursing Home Beacon Road Ivybridge Plymouth PL21 0AQ Lead Inspector Doug Endean Unannounced Inspection 10th January 2007 10:45 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 Beaconville Nursing Home DS0000050213.V319808.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. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaconville Nursing Home Address Beacon Road Ivybridge Plymouth PL21 0AQ 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) 01752 896505 01752 895418 a.taylor@21stcenturycare.co.uk www.21stcenturycare.co.uk 21st Century Care (Plymouth) Ltd Anne Taylor Care Home 36 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (36), Mental disorder, excluding learning of places disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (36) Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The categories of registration will be DE(E) (36), MD(E) (36), DE(5), MD(5). The home will be occupied by a maximum of 36 service users. 13/01/06 Date of last inspection Brief Description of the Service: Beaconville Nursing Home is a large detached building (originally two large houses) within its own walled grounds and is in close proximity to the town centre of Ivybridge, on the edge of Dartmoor National Park in Devon. It is approximately 15 miles from Plymouth, which is accessed by the A38 that runs past Ivybridge. There are two separate entrances into the grounds with driveways leading to the main doors and limited parking spaces. The building has been extended to the rear and side of the main house that provides additional single and double room accommodation at ground and mezzanine floor levels. There are twenty-six single rooms, three with en-suites and five double rooms. The home has good provision of services for people with physical disabilities such as Parker baths, hoists and a shaft lift from the first to the mezzanine floor. Several steps are encountered to progress further to the 1st floor. The homes primary registration is to meet the needs of elderly people with a dementia or mental disorder. It employs qualified nursing staff to lead the Social Care staff to achieve this aim. The home’s design provides two lounges and two dining rooms where recreational activities can take place in addition to their main functions. There is now also a brick built conservatory linking both lounges creating a level walking area for ambulant service users. Several of the Service Users rooms are very large providing space well above the required minimum space. A hotel style kitchen produces the meals for all the Service Users. The home has set its fee, at this point in time, at £553 including the funded nursing care contribution. There are separate charges for such things as hairdressing, chiropody and personal items such as clothing. Invoices are produced by the homes Administrator. The company has recently changed hands, which has effectively changed the management of the business but not the home itself. The companies website that describes the service at Beaconville will need to be changed as a result of this. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 10th January 2007 beginning at 10:45 and lasting six hours. In this time the inspector made a full tour of the building, spoke to two visiting relatives and three staff members including the Registered Manager. He made his own observations of the staff in the course of their duties caring for the service users at different times of the day and with differing needs. The Registered Manager had provided a completed Pre-Inspection Questionnaire some weeks before this unannounced inspection took place. The inspector also received two completed relatives comment cards, six completed care workers survey cards and two service users survey cards completed on their behalf by relatives. Information held in the pre-inspection questionnaire was verified as training and maintenance records were looked at. Three service users were case tracked. This involved meeting the service users and reviewing the information held on them including their care plans. One of the relatives spoken to was the relative of a service user who was case tracked. What the service does well: What has improved since the last inspection? The Registered Manager told me that the home has looked at the quality of the meals provided and the choices of food and presentation. There is now a new menu with greater choice of meals both cooked and cold. The design of the communal space has improved with the building of a conservatory between the two lounges that does allow ambulant service users to wander safely within the confines of the ground floor area of the home. The Registered Manager has now completed the Registered Managers Award, National Vocational Qualification level 4. The Deputy Manager and one other Registered Nurse has also completed this award. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Beaconville Nursing Home DS0000050213.V319808.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 Beaconville Nursing Home DS0000050213.V319808.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 1, and 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 Statement of Purpose and other information for service users and their advocates is well written and very informative. The home does gather and record a sufficient amount of information to enable them to make a judgement about the suitability of a referred individual. EVIDENCE: There is a Statement of Purpose, service users guide and website that provides valuable information to the reader including the Office of Fair Trading document “Fair Terms for Care”, National Health Service Funded Nursing Care and a Care Aware helpline document. The inspector looked at the case records of three service users. There was a completed pre-admission assessment (service users enquiry) for each of these Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 9 service users. Each one held enough information for the manager to make a decision about the suitability of the home for the service user. The assessments were carried out either by the Registered Manager or one of the other Registered Nurses. On admission further information was taken of a more detailed nature for each of person. The inspector read this information, as well as other information held in care plans, such as risk assessments for falls, behaviour, and manual handling and found that it did support the decision to admit the individuals. Beaconville Nursing Home DS0000050213.V319808.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff are skilled in making good assessments of service users. The care planning meets the assessed needs of service users in a manner that shows respect and maintains their dignity using the resources in the home and the community. EVIDENCE: Each of the three service users case records that were read held a variety information that had been used to form the care plans. This information included the pre-admission assessment, risk assessments for behaviour, falls, tissue viability and manual handling. The care plans were written clearly giving information about the problems that had been identified and the action that was planned to address the problems. Some care plans were pre-determined using a standard format that were then individualised for each of the service Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 11 users they described. There was also a separate plan of care for night care needs. The care plans had evidence of them being regularly reviewed and this was verified during the case tracking of one person who was unwell at the time of the inspection as her care plan covered her most recent assessed needs very well. The case records also included a daily account of the care offered and received as well as information regarding the General Practitioner interventions. The inspector looked at the arrangements for the storage and administration of medication and found them to be good. There is a dedicated room for the medication and dressings, which is securely locked, as are the medication cabinets. The medication trolley is also securely tethered to the wall when not in use even though it is locked and kept within a locked room. There is a medications fridge and the inspector saw the daily record of its temperature. There was reference information regarding medication and the selected staff have access to the internet via the homes broadband connection to research the latest information about medication that comes into the home. Medication administration records are good as a professionally prepared format is used. The service users were not able to provide the inspector with a rational response to any questioning as a result of their dementia. However the relatives who responded on the two comment cards and two service users survey forms provided evidence of their view that the service users are treated with dignity and respect. One relative made the comment “It’s a sad time for us as a family, but if I won the lottery this home is still the place I would want my Mum to spend the rest of her life in”. This indicates a high level of satisfaction to the inspector. This was also supported by one relative who was spoken to during the inspection who told the inspector “You will not find anything wrong with this home”. The home does have a relatives support group who now meet less formally at the home than in the past but still provide an advocacy role for the service user. The service users who were unwell and in bed at the time of this inspection were seen to be regularly visited by the staff who used a form to record the time of their visits and the content of there visit such as assisting with a meal or changing the bed. They were afforded privacy and dignity in their own rooms and did look comfortable. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 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 many suitably varied activities for the clients. The approach that is adopted by the staff enables the patients to express their individualism despite their disability. The menus present a variety of meals with good nutritional value presented in a manner that the service users recognize and will eat. EVIDENCE: The home provides entertaining and therapeutic activities on a managed and impromptu basis. They arrange for outside providers and the staff who work at the home to carry out the activities. The activities are designed to meet the specific needs of the Service Users at the home who do have memory problems and short-term attention spans. A board in the dining room provides information about activities planned for the whole of the current month. On offer are such things as exercise to music, tranquil moments that includes involving the service users in poetry and playing instruments. The visiting Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 13 hairdresser was working in the home during the inspection. Information has been gathered and recorded on each of the service users in their “Life Cycle record” about their hobbies and interests and the activities have been planned to meet these where possible. The Friends of Beaconville (a relatives group) are also able to pass comment on activities that may be provided at the home. The two lounges have been physically linked by a brick built conservatory that now adds a good deal of level space for the service users to walk in should they wish to do so. Visiting can take place at any reasonable time. Relatives are informed of this verbally and in the statement of purpose. A number of visitors were in the home during the period of this inspection and two was spoken to who gave positive comments about the care her relative receives. Visiting can take place in any of the communal areas or in the privacy of the patients own room if they wish. The patients exercise choice in many ways despite their disabilities. The staff are experienced in understanding when a patient is expressing a view such as not liking the cloths that are offered them or the food at a meal time. The admission process also includes gaining information from relatives and friends about likes and dislikes in the “Life Cycle record”. These were seen in the three case files sampled by the inspector and included information such as what time the patient prefers to go to bed and what foods they like or dislike. Patients may bring personal possessions into the home. The inspector saw that some rooms were personalized. One staff survey form had commented that the meals could improve in cooking and presentation whilst one relative stated on the service users survey “Meals are very good”. The Registered Manager said that the quality of meals had been an issue that had recently been addressed and presented a copy of a new menu sheet. Breakfasts now present a wider choice of cooked and un-cook items and there is a wider selection for the other meals of the day. Some service users do tell staff what they would chose to eat for their main meal in advance whilst the Life Cycle and relatives guide the staff to offer meals to others that they may have chosen for themselves. Meals are constructed and presented in ways that satisfy also the service users nutritional needs that had been assessed and recorded. The inspector saw the service users enjoying their main meal. The kitchen is well managed and the Cook has got to grips with the latest food regulations. He has attended a workshop on “Safer Food, Better Business” and produced his records for the inspector. Food was stored correctly in fridges, freezers and the dry stores. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints procedure, recruitment procedure and adult protection training and procedures provide satisfactory measures to identify and deal with problems relating to any area of abuse. EVIDENCE: All visitors are asked to sign in and out when they visit the home in the book provided at the main entrance of the home. There is a complaints procedure displayed at each of the two entrances to the home that does have clear information including how to contact the Commission for Social Care Inspection should this be necessary. Each copy of the Statement of Purpose also has a copy of the complaints procedure. The homes record of complaints is held on computer and includes the way the complaint was investigated and resolved. The Commission for Social Care Inspection has not received any complaints about the home in this inspection year. The home has its own policies and procedures relating to the care of vulnerable adults. This information includes the Alerters guide and training video from the local authority. The staff are required to watch the video and read the policies and then sign that they have done this to show compliance. Those who have been involved in the National Vocational Qualification training have also been Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 15 introduced to this issue as part of that training. The homes recruitment “life cycle” procedure also covers the issue of protection through Protection of Vulnerable Adults. The home has several Care Aware leaflets that they give to advocates of the clients including one relating to Advocacy. As further protection the home does carry out a Criminal Records Bureau and POVA list check on every new employee. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 19, 20, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides suitably adapted and maintained accommodation for the service users to live in that is clean and well maintained. EVIDENCE: The inspector toured the home including bedrooms, bathing facilities, lounges and the dining areas. All areas were suitably decorated and furnished with some areas having been redecorated so that they look fresh and homely in appearance. A shaft lift provides access from the ground floor to the mezzanine floor. There are seven steps from this level to the first floor on the main side of the building. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 17 The bedrooms are of suitable size and shape for the care that is generally provided to the clients at the home. Each room is adequately furnished by the home and many were seen to be personalized using possessions that the clients have brought into the home. Floor coverings vary according to the needs of the clients with there being a predominance of carpets to most rooms. There are some double rooms and these have privacy screens provided so that personal and nursing care can be provided whilst preserving the privacy and dignity of the clients. The home has a variety of styles of beds provided and the new owners are replacing many beds with attractive, yet functional, nursing beds that are height and mattress adjustable as is already in some bedrooms. Three of these new beds were delivered on the day of inspection and put into immediate use. The two lounge areas provide extensive communal space for the service users as they are linked by a brick built conservatory. Bathing areas offer a variety of facilities from wet rooms to disabled bathing facilities that have Parker baths in them. Information on equipment maintenance was provided by the Registered Manager in the pre-inspection form. The inspector verified this information when he looked at invoices and service sheets during the inspection, as well as the general state of repair of the home during the tour of the establishment. The home employs a Housekeeper who manages the domestic staff who collectively keep the home clean and well presented. Cleaning materials are stored safely behind two locked doors and there are details of all the cleaning materials that are used by the home in a COSHH folder in the office. The home does have substantial grounds that the service users do have access to in good weather. Access is to improve when the planned new car park is established. The Registered Manager told the inspector that the new owners have plans to totally refurbish the home and also to build a new extension increasing the bed numbers and providing a new laundry that is presently in a building opposite the main entrance of the home. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home does provide a more than satisfactory level of appropriate training for the staff who they have recruited. The staff does communicate very well with the service users and their advocates. EVIDENCE: The Registered Manager, who is a Registered Mental Nurse has employed a team of Registered Nurses, both general and psychiatric, and trained care staff in sufficient numbers who collectively offer a mix of skills and experience to meet the needs of the service users. Staff retention at this home is good. Six staff responded to the care workers survey and each voiced a good level of satisfaction with their employment. One staff member commented, “This care home is the best I have worked in” whilst another wrote” Cares well for the individual needs of the residents and supports families/cares when a resident enters the terminal stages of their illness”. The duty sheets provided evidence that the home is adequately staffed by day and by night with a Registered Nurse leading each shift. There has been a large commitment given to staff training with more than 50 of care staff having achieved a National Vocational Qualification in care. Of those with the National Vocational Qualification 66 have achieved either Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 19 level 3 or level 4. The Registered Manager and her Deputy, plus one other nurse have the Registered Manager Award (level 4 in Management) and several staff are involved in level 4 training in care. The Manager provided a list of the staff training that has taken place in 2006 that shows all staff have had an update in fire training and five staff are Moving and Handling instructors. One member of staff is a trained Fire Warden and is responsible for staff training and also monitoring all the fire safety arrangements in the home. The home has its own professionally produced DVD of fire training made in the home so that it is relevant and fit for the purpose when show to the staff. Four staff had completed the Basic Health and Safety training. The Cook has been employed at the home for two years. In that time he has completed the Foundation food hygiene course and also the Safer Food, Better Business workshop. The homes recruitment procedure includes them obtaining references and a Criminal Records Bureau check for each staff member. There are some overseas staff employed at the home for which the home holds work permits. Three staff files provided evidence that the home follow their recruitment procedures fully and thereby protect the service users. The home also has a series of questions for each new member of staff to respond to in writing and also at interview that address the equal opportunities requirements. The information given is recorded on an interview questionnaire form that is kept in the staff members file. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standards 31, 33, 35 and 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 managed very well internally and has very good ways of providing evidence that they have achieved their aims and objectives. There are good measures in place to meet the health, safety and welfare of the service users. EVIDENCE: The Registered Manager is an experienced first level nurse with proven management skills and a good deal of experience in caring for the elderly person who has a mental health problem. She has now achieved the Registered Managers Award to add to her Registered Mental Nurse Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 21 qualification. The Registered Manager explained the new external management structure to the inspector. The home has a series of “Life Cycle” tools that clearly show the level of completion and therefore achievement of each task that they appertain too such as recruitment of staff or the admission process of a new patient. This is a good measure of quality assurance for each task undertaken. In addition to this staff meetings (minutes taken) and regular group meetings with the patients relatives are also part of the homes quality assurance tools. A further measure is the questionnaire that is passed to relatives and friends of patients for them to comment on the care and home environment. The Friend of Beaconville group, made up of service users relatives, now meets on a less formal basis then in the past but still has a function in commenting on standards. The clients are not able to manage their own financial affairs and the home will advise an advocate to make suitable arrangements for this issue to be managed in the best interests of both parties. The home has Care Aware leaflets on “Enduring Power of Attorney” and other subjects for the advocates of service users to read and inform themselves of the steps they may need to take to safeguard the service users affairs. Where purchases are made by the home that are not within the contractual agreement, such as hair dressing, chiropody and possibly clothing the home will have an agreement to pay for the items then invoice the appropriate person for recompense. The home employs an Administrator who handles all the financial business of this nature. The Administrator has clear records of all financial dealings involving the home that were not inspected on this occasion. The Registered Manager has provided a high level of good training for the staff that is appropriate to the task they become involved in as part of their duties. See the comments in the “staffing section” of this report for more detail. This has meant that staff practice in a safe way using equipment that has been regularly serviced by a competent person. The training has included al staff who work in the home both in care and in the ancillary services. The knowledge that staff has been demonstrated in such things as how drugs are stored and administered and how cleaning materials are stored and COHSS information is available. The home has up to date policies and procedures that are functional documents and readily available to the staff on duty. The policies and procedures on how fire risk is managed were looked at by the inspector along side the active fire records that demonstrated that they were understood. The home has recorded accidents clearly and use the Regulation 37 notice to keep the Commission for Social Care Inspection informed of appropriate information. Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 22 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 3 9 4 10 4 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 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Beaconville Nursing Home DS0000050213.V319808.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!